Adverse Effects of α-2 Adrenergic Agonists and Stimulants in Preschool-age Attention-deficit/Hyperactivity Disorder: A Developmental-Behavioral Pediatrics Research Network Study.

OBJECTIVES: To characterize and compare the type and frequency of a range of common and uncommon adverse effects (AEs) associated with α-2 adrenergic agonist (A2A) and stimulant treatment of attention-deficit/hyperactivity disorder at preschool-age as well as to evaluate the impact of age on common AEs. STUDY DESIGN: This was a retrospective electronic medical record review of children <72 months of age (n = 497) evaluated at outpatient developmental-behavioral pediatric practices at 7 US academic medical centers within the Developmental-Behavioral Pediatrics Research Network. Data on AEs were abstracted for children who had treatment initiated by a developmental-behavioral pediatrician with an A2A or stimulant medication between January 2013 and July 2017; follow-up was complete by February 2019. RESULTS: A2A and stimulants had distinctive AE profiles. A2A compared with stimulants had a greater proportion with daytime sleepiness and headaches; stimulants had significantly greater proportions for most other AE, including moodiness/irritability, difficulty with sleep, appetite suppression, stomachaches, skin picking/repetitive behaviors, withdrawn behavior, and weight loss. Younger age was associated with disruptive behavior and difficulty with sleep. CONCLUSIONS: Stimulants had a greater rate of most AEs compared with A2A. AE profiles, together with efficacy, should inform clinical decision-making. Prospective randomized clinical trials are needed to fully compare efficacy and AE profiles of A2A and stimulants.

Barcoding, linear and nonlinear analysis of full-day leg movements in infants with typical development and infants at risk of developmental disabilities: Cross-sectional study.

Traditional methods do not capture the multidimensional domains and dynamic nature of infant behavioral patterns. We aim to compare full-day, in-home leg movement data between infants with typical development (TD) and infants at risk of developmental disabilities (AR) using barcoding and nonlinear analysis. Eleven infants with TD (2-10 months) and nine infants AR (adjusted age: 2-14 months) wore a sensor on each ankle for 7 days. We calculated the standard deviation for linear variability and sample entropy (SampEn) of leg acceleration and angular velocity for nonlinear variability. Movements were also categorized into 16 barcoding states, and we calculated the SampEn and proportions of the barcoding. All variables were compared between the two groups using independent-samples t-test or Mann-Whitney U test. The AR group had larger linear variability compared to the TD group. SampEn was lower in the AR group compared to TD group for both acceleration and angular velocity. Two barcoding states' proportions were significantly different between the two groups. The results showed that nonlinear analysis and barcoding could be used to identify the difference of dynamic multidimensional movement patterns between infants AR and infants with TD. This information may help early diagnosis of developmental disabilities in the future.

Hyperactivity and Impulsivity Symptoms Mediate the Association Between Adverse Childhood Experiences and Reading Achievement: A LONGSCAN Cohort Study.

Adverse Childhood Experiences (ACEs) include various childhood stressors that can negatively impact the health and well-being of children. ACEs are associated with poor academic achievement. Attention is strongly associated with academic achievement, and there is a graded relationship between ACEs exposure and subsequent development of parent-reported ADHD; however, it is unclear whether ADHD symptoms mediate the relationship between ACEs and academic achievement. This study tested a model of mediation by ADHD symptoms between ACEs and academic achievement (measured by reading score). This retrospective cohort analysis utilized data from the Longitudinal Study on Child Abuse and Neglect (LONGSCAN), a data consortium exploring the impact of child maltreatment (n = 494). There were relatively even numbers of male and female child participants, and the majority of caregivers were either non-Hispanic White or Black. Path analyses were modeled for ACEs as a sum score and separately for individual ACE exposures, with number of symptoms of Inattention (IN) and Hyperactivity/Impulsivity (H/I) as mediators, and academic achievement as the outcome, adjusting for covariates. ACEs were highly prevalent in this sample (M = 5.10, SD = 1.90). After retaining significant covariates, significant direct associations (P < .05) were seen between ACE sum score and IN (ß = .14) and H/I (ß = .21), and between H/I and reading score (ß=-.14). A higher ACE score was associated with lower reading scores through variation in H/I, but not IN. H/I mediated the relationship between ACEs and reading score in this high-risk population, providing new insight into relationships between ACEs and academic achievement, which can inform interventions.

Leg Movement Rate before and after a Caregiver-Provided Intervention for Infants at Risk of Developmental Disability: A Pilot Study.

AIM: Our purpose was to assess daily leg movement rate before and after a caregiver-provided in-home intervention for infants at risk for developmental disability. We also assessed adherence and quality of caregiver-child interaction. METHODS: Twelve infants, at risk for developmental disabilities, and their caregivers participated in an intervention focused on increasing leg movements. Intervention started between 3- and 6-months corrected age and ended once the infant was able to sit independently or at 9 months corrected age, whichever occurred first. Infants were assessed monthly. RESULTS: Infants at risk for developmental disabilities who were moving less than 1200 leg movements per hour awake at the start of the intervention increased their daily leg movement rate following the intervention (Median [range]: pre-1047 [506-1056], post- 1104 [655-1359], p = 0.040). Additionally, the caregivers had a high adherence (Median: 89%, Range: 11.43%-329.17%) and good quality of caregiver-child interaction (Median NCAST total: 46, Range: 34-59); and maintained similar amounts of adherence (p = 0.575) and quality of caregiver-child interaction (p = 0.432) throughout the intervention. CONCLUSION: This study provides preliminary evidence that leg movement rate has the potential to be used as an outcome measure to assess an infant's progress and motor practice during an intervention.

Fetal neurodevelopmental recovery in donors after laser surgery for twin-twin transfusion syndrome.

BACKGROUND: Fetal magnetic resonance imaging (MRI) and spectroscopy (MRS) provide a unique opportunity to non-invasively measure markers of neurodevelopment in survivors of twin-twin transfusion syndrome (TTTS). OBJECTIVE: To characterize fetal brain maturation after laser surgery for TTTS by measuring brain volumes and cerebral metabolite concentrations using fetal MRI + MRS. STUDY DESIGN: Prospective study of dual surviving fetuses treated with laser surgery for TTTS. At 4-5 postoperative weeks, fetal MRI was used together with novel image analysis to automatically extract major brain tissue volumes. Fetal MRS was used to measure major metabolite concentrations in the fetal brain. RESULTS: Twenty-one twin pairs were studied. The average (±SD) gestational age at MRI was 25.89 (±2.37) weeks. Total brain volume (TBV) was lower in the donors, although cerebral volumes were not different between twin pairs. Recipients showed lower proportions of cortical and cerebellar volumes, normalized to TBV and cerebral volumes. MRS data showed that biochemical differences between twin brains were related to discrepancy in their brain volumes. CONCLUSION: Although donors have a smaller TBV compared to recipients, proportionality of brain tissue volumes are preserved in donors. MRS maturational markers of fetal brain development show that recovery in donors persists 4 weeks after surgery.

Maternal post-traumatic stress and depression symptoms and outcomes after NICU discharge in a low-income sample: a cross-sectional study.

BACKGROUND: Having a preterm newborn and the experience of staying in the neonatal intensive care unit (NICU) has the potential to impact a mother's mental health and overall quality of life. However, currently there are few studies that have examined the association of acute post-traumatic stress (PTS) and depression symptoms and infant and maternal outcomes in low-income populations. DESIGN/ METHODS: In a cross-sectional study, we examined adjusted associations between positive screens for PTS and depression using the Perinatal Post-traumatic stress Questionnaire (PPQ) and the Patient Health-Questionnaire 2 (PHQ-2) with outcomes using unconditional logistic and linear regression models. RESULTS: One hundred sixty-nine parents answered the questionnaire with 150 complete responses. The majority of our sample was Hispanic (68%), non-English speaking (67%) and reported an annual income of <$20,000 (58%). 33% of the participants had a positive PPQ screen and 34% a positive PHQ-2 screen. After adjusting for confounders, we identified that a positive PHQ-2 depression score was associated with a negative unit (95% CI) change on the infant's Vineland Adaptive Behavior Scales, second edition of - 9.08 (- 15.6, - 2.6) (p < 0.01). There were no significant associations between maternal stress and depression scores and infant Bayley Scales of Infant Development III scores or re-hospitalizations or emergency room visits. However, positive PPQ and screening score were associated with a negative unit (95% CI) unit change on the maternal Multicultural Quality of Life Index score of - 8.1 (- 12, - 3.9)(p < 0.01) and - 7.7 (- 12, - 3) (p = 0.01) respectively. CONCLUSIONS: More than one-third of the mothers in this sample screened positively for PTS and depression symptoms. Screening scores positive for stress and depression symptoms were associated with a negative change in some infant development scores and maternal quality of life scores. Thoughtful screening programs for maternal stress and depression symptoms should be instituted.

The association of care transitions measure-15 score and outcomes after discharge from the NICU.

BACKGROUND: Our objectives were (1) to describe Care Transitions Measure (CTM) scores among caregivers of preterm infants after discharge from the neonatal intensive care unit (NICU) and (2) to describe the association of CTM scores with readmissions, enrollment in public assistance programs, and caregiver quality of life scores. METHODS: The study design was a cross-sectional study. We estimated adjusted associations between CTM scores (validated measure of transition) with outcomes using unconditional logistic and linear regression models and completed an E-value analysis on readmissions to quantify the minimum amount of unmeasured confounding. RESULTS: One hundred sixty-nine parents answered the questionnaire (85% response rate). The majority of our sample was Hispanic (72.5%), non-English speaking (67.1%) and reported an annual income of <$20,000 (58%). Nearly 28% of the infants discharged from the NICU were readmitted within a year from discharge. After adjusting for confounders, we identified that a positive 10-point change of CTM score was associated with an odds ratio (95% CI) of 0.74 (0.58, 0.98) for readmission (p = 0.01), 1.02 (1, 1.05) for enrollment in early intervention, 1.03 (1, 1.05) for enrollment in food assistance programs, and a unit change (95% CI) 0.41 (0.27, 0.56) in the Multicultural Quality of Life Index score (p < 0.0001). The associated E-value for readmissions was 1.6 (CI 1.1) suggesting moderate confounding. CONCLUSION: The CTM may be a useful screening tool to predict certain outcomes for infants and their families after NICU discharge. However, further work must be done to identify unobserved confounding factors such as parenting confidence, problem-solving and patient activation.

Risk Factors for Parenting Stress in Parents of Children Treated with Laser Surgery for Twin-Twin Transfusion Syndrome 2 Years Postpartum.

OBJECTIVE: Twin-twin transfusion syndrome (TTTS) is a rare but serious condition that can occur in monochorionic and diamniotic twin pregnancies. Research indicates almost half of postpartum mothers with TTTS may have clinically significant levels of stress. However, no studies have measured the levels of parenting stress at 2 years postpartum, and little research has been conducted on sources of stress. STUDY DESIGN: A prospective cohort study was conducted. Data were collected from parents whose children were treated with laser ablation in utero and were 2 years old at the time of screening. The Parenting Stress Index - Short Form (PSI-SF) and its three subscales were used to collect data. Descriptive, bivariate, and multivariate analyses were conducted to determine significant predictors associated with each outcome. RESULTS: A total of 99 children from 56 families were enrolled. Unmarried status (B = -22.8; p = 0.039) and lower maternal educational level (B = -7.8; p = 0.01) were both significantly associated with higher PSI-SF total score. CONCLUSION: Subgroups of parents whose pregnancy required laser surgery for TTTS may continue to have clinically significant levels of stress at 2 years postpartum. It is important the health care team is aware of this and the sociodemographic risk factors to provide appropriate support for families.

α2-Adrenergic Agonists or Stimulants for Preschool-Age Children With Attention-Deficit/Hyperactivity Disorder.

Importance: Attention-deficit/hyperactivity disorder (ADHD) is diagnosed in approximately 2.4% of preschool-age children. Stimulants are recommended as first-line medication treatment. However, up to 25% of preschool-age children with ADHD are treated with α2-adrenergic agonist medications, despite minimal evidence about their efficacy or adverse effects in this age range. Objective: To determine the frequency of reported improvement in ADHD symptoms and adverse effects associated with α2-adrenergic agonists and stimulant medication for initial ADHD medication treatment in preschool-age children. Design, Setting, and Participants: Retrospective electronic health record review. Data were obtained from health records of children seen at 7 outpatient developmental-behavioral pediatric practices in the Developmental Behavioral Pediatrics Research Network in the US. Data were abstracted for 497 consecutive children who were younger than 72 months when treatment with an α2-adrenergic agonist or stimulant medication was initiated by a developmental-behavioral pediatrician for ADHD and were treated between January 1, 2013, and July 1, 2017. Follow-up was complete on February 27, 2019. Exposures: α2-Adrenergic agonist vs stimulant medication as initial ADHD medication treatment. Main Outcomes and Measures: Reported improvement in ADHD symptoms and adverse effects. Results: Data were abstracted from electronic health records of 497 preschool-age children with ADHD receiving α2-adrenergic agonists or stimulants. Median child age was 62 months at ADHD medication initiation, and 409 children (82%) were males. For initial ADHD medication treatment, α2-adrenergic agonists were prescribed to 175 children (35%; median length of α2-adrenergic agonist use, 136 days) and stimulants were prescribed to 322 children (65%; median length of stimulant use, 133 days). Improvement was reported in 66% (95% CI, 57.5%-73.9%) of children who initiated α2-adrenergic agonists and 78% (95% CI, 72.4%-83.4%) of children who initiated stimulants. Only daytime sleepiness was more common for those receiving α2-adrenergic agonists vs stimulants (38% vs 3%); several adverse effects were reported more commonly for those receiving stimulants vs α2-adrenergic agonists, including moodiness/irritability (50% vs 29%), appetite suppression (38% vs 7%), and difficulty sleeping (21% vs 11%). Conclusions and Relevance: In this retrospective review of health records of preschool-age children with ADHD treated in developmental-behavioral pediatric practices, improvement was noted in the majority of children who received α2-adrenergic agonists or stimulants, with differing adverse effect profiles between medication classes. Further research, including from randomized clinical trials, is needed to assess comparative effectiveness of α2-adrenergic agonists vs stimulants.

Collecting Infant Environmental and Experiential Data Using Smartphone Surveys.

We propose that the collection of infant experiential and environmental data using smartphone surveys has the potential to fill a gap in foundational and clinical knowledge. To achieve this, these data need to be collected in a systematic way that is translatable globally. We can then begin to understand differences in child development and physical therapy from a variety of cultures and traditions. An infant's development is shaped by experiences in everyday life, and everyday experiences vary around the world. Hence, it is important to quantify these experiences to better understand variability in developmental trajectories. Recent increase in smartphone access has made the capability of collecting infant experiential data more feasible around the world. We provide examples and suggestions for ways in which experiential and environmental data can be collected for future practice.

Maternal Depressive Symptoms and Developmental Delay at Age 2: A Diverse Population-Based Longitudinal Study.

OBJECTIVES: Children raised by depressed mothers perform lower on measures of cognitive, emotional, and behavioral skills, compared to children of non-depressed mothers. It is unclear how maternal depressive symptoms (MDS), which persist and accrue over time, impact child development. The purpose of this study was to determine whether cumulative MDS from pre-pregnancy to postpartum influences child development in children by age 2.5. METHODS: Using a longitudinal population-based study design, 2679 racially and ethnically diverse mothers completed the 2014 Los Angeles Mommy and Baby (LAMB) and 2016 Follow-Up surveys. A total MDS score was created based on responses to standardized questions, including the Patient Health Questionnaire-2 (PHQ-2). Data was collected for before pregnancy, during pregnancy, and 4 months postpartum in the 2014 survey, and at 2.5 years postpartum in the 2016 survey. Child development was measured using the CDC's Learn the Signs. Act Early Milestones Checklist. Bivariate and multivariate logistic regressions were conducted. RESULTS: The prevalence of any cumulative MDS was 45.2%. Language, cognitive/adaptive, motor, and social-emotional delays for surveyed toddlers were 7.7%, 4.0%, 1.2%, and 14.2%. After adjusting for covariates, mothers reporting depressive symptoms at all four time points were significantly more likely to report a social-emotional delay in their child (aOR = 4.39, 95% CI - 1.72 to 11.18). CONCLUSIONS FOR PRACTICE: Mothers with cumulative depressive symptoms are at-risk of reporting social-emotional delays by age 2.5. Understanding these effects may help direct resources to target interventions that support mothers with depressive symptoms early-on and promote positive developmental outcomes among their children.

How Many Days are Necessary to Represent Typical Daily Leg Movement Behavior for Infants at Risk of Developmental Disabilities?

BACKGROUND: Movement characteristics can differentiate between infants at risk and infants with typical development. However, it is unknown how many days are needed to accurately represent typical daily behavior for infants at risk of developmental disabilities when using wearable sensors. To consider the balance between participant burden and the amount of data collected and optimizing the efficiency of data collection, our study determined (1) how many days were necessary to represent typical movement behavior for infants at risk of developmental disabilities and (2) whether movement behavior was different on weekend days and weekdays. METHODS: We used Opal wearable sensors to collect at least 5 days of 11 infants' leg movement data. The standard (average of 5 days) was compared with four methods (average of the first 1/2/3/4 days) using the Bland-Altman plots and the Spearman correlation coefficient. We also compared the data from the average of 2 weekend days to the average of the first 2 weekdays for 8 infants. RESULTS: The Spearman correlation coefficient comparing the average of the first 2 days of data and the standards were all above 0.7. The absolute differences between them were all below 10% of the standards. The Bland-Altman plots showed more than 90% of the data points comparing the average of 2 days and the standards fell into the limit of agreement for each variable. The absolute difference between weekend days and weekdays for the leg movement rate, duration, average acceleration, and peak acceleration was 15.2%, 1.7%, 6.8% and 6.3% of the corresponding standard, respectively. CONCLUSION: Our results suggest 2 days is the optimal amount of data to represent typical daily leg movement behavior of infants at risk of developmental disabilities while minimizing participant burden. Further, leg movement behavior did not differ distinctly across weekend days and weekdays. These results provide supportive evidence for an efficient amount of data collections when using wearable sensors to evaluate movement behavior in infants at risk of developmental disabilities.

Viewpoints from families for improving transition from NICU-to-home for infants with medical complexity at a safety net hospital: a qualitative study.

BACKGROUND: We have limited information on families' experiences during transition and after discharge from the neonatal intensive care unit. METHODS: Open-ended semi-structured interviews were conducted with English or Spanish- speaking families enrolled in Medicaid in an urban high-risk infant follow up clinic at a safety-net center, which serves preterm and high-risk term infants. We generated salient themes using inductive-deductive thematic analysis. RESULTS: Twenty-one participants completed the study. The infant's median (IQR) birth weight was 1750 (1305, 2641) grams; 71% were Hispanic and 10% were Black non-Hispanic; 62% reported living in a neighborhood with 3-4th quartile economic hardship. All were classified as having chronic disease per the Pediatric Medical Complexity Algorithm and 67% had medical complexity. A conceptual model was constructed and the analysis revealed major themes describing families' challenges and ideas to support transition centered on the parent-child role and parent self-efficacy. The challenges were: (1) comparison to normal babies, (2) caregiver mental health, (3) need for information. Ideas to support transition included, (1) support systems, (2) interventions using mobile health technology (3) improved communication to the primary care provider and (4) information regarding financial assistance programs. Specific subthemes differed in frequency counts between infants with and without medical complexity. CONCLUSIONS: Families often compare their preterm or high-risk infant to their peers and mothers feel great anxiety and stress. However, families often found hope and resilience in peer support and cited that in addition to information needs, interventions using mobile health technology and transition and financial systems could better support families after discharge.

In utero Fetal Intubation for a Large Neck Mass: A Minimally Invasive EXIT Option.

Fetuses with obstructive neck and orofacial lesions have been delivered via an ex utero intrapartum treatment (EXIT) procedure to facilitate securement of the airway while on placental circulation. Pregnancy-related cardiovascular changes and technical issues unique to an EXIT procedure increase fetal and maternal risks relative to a standard cesarean section. In order to circumvent such issues, fetal endoscopic intubation has been proposed. We report a case of a fetus with a large neck mass (mixed solid and multiloculated cystic lesion measuring 9.2 × 5.3 × 8.5 cm, neck hyperextension, protruding tongue, and serial gagging movements) that was successfully intubated in utero and delivered at 36 weeks and 0 days via standard cesarean section, thereby avoiding an EXIT procedure. The risks, benefits, and technical issues of in utero tracheal intubation are reviewed.

The relationship between preoperative fetal head circumference and 2-year cognitive performance after laser surgery for twin-twin transfusion syndrome.

OBJECTIVE: To determine the relationship between preoperative fetal head circumference (HC) and cognitive performance among children treated with laser surgery for twin-twin transfusion syndrome (TTTS). METHODS: Donor and recipient twin HCs were measured preoperatively (16-26 weeks' gestation) and at 2 years corrected age. Multilevel multivariate regression models were used to test pregnancy and child-level risk factors for lower Battelle Developmental Inventory Second Edition (BDI-2) scores. A repeated-measures ANOVA was used to examine HC growth among recipients and donors between preoperative and 2 years. RESULTS: Ninety-nine children were evaluated. The average BDI-2 score for the cohort was 101.4 (SD = 12.2). After controlling for covariates, larger preoperative HC percentiles were significantly associated with an increase in total BDI-2 scores (ß = 0.29; P < 0.001), where a 12.5% increase in preoperative HC percentile was associated with 1-point increase in total BDI-2 score. The mean recipient and donor twin HC percentiles preoperatively and at age 2 years were 51st percentile vs 20th percentile (P = .050) and 60th percentile vs 49th percentile (P = .676), respectively. CONCLUSION: Smaller preoperative HC percentiles identified children at risk of lower, but still within normal range, total BDI-2 scores. The discordance in HC percentiles between the donor and recipient twin decreased after laser surgery.

The Interprofessional/Family-Centered-Care Observation Rubric (I-FOR): Results of a Multicenter Study of a New Measure of Educational Outcomes.

Introduction The ability to provide family-centered care (FCC) and the ability to work in interprofessional care teams (IPC) are essential educational outcomes in graduate training programs. Lack of standardized measures leave programs to rely on idiosyncratic methods to monitor outcomes. We developed a faculty observation tool as part of an effort to create a national quality improvement database. We present evidence for the feasibility and validity of the faculty observation tool. Methods Trainees and faculty at four independent training programs participated. Nineteen maternal and child health disciplines were represented. Faculty supervisors rated trainees using the new measure (I-FOR), and trainees completed related subscales of a previously developed self-report measure, the core competency measure (CCM). Faculty provided qualitative feedback regarding the I-FOR in a separate questionnaire. Results Faculty (n = 78) completed the I-FOR on 86 trainees (86/92 = 93%) and reported satisfaction with completing the measures. The I-FOR demonstrated good internal consistency (Cronbach's alpha > 0.930) and test-retest reliability (IPC r = 0.862, FCC r = 0.823, p < 0.001). Greater than 95% of participants reported that the I-FOR accurately addressed the relevant skills for each practice domain. The I-FOR showed no correlation with the CCM. Significant improvements over time in the I-FOR ratings were demonstrated in three out of four programs. Discussion The I-FOR demonstrated good internal consistency and test-retest reliability. Faculty responses provide evidence for the feasibility and validity of the instrument. Self-report and faculty-observation measures both increased with training but were not correlated with each other.

Fetal brain-sparing after laser surgery for twin-twin transfusion syndrome appears associated with two-year neurodevelopmental outcomes.

OBJECTIVE: The cerebroplacental ratio (CPR) is a semi-quantitative marker for fetal brain-sparing. Our purpose was to measure the CPR at the time of treatment with selective laser photocoagulation of communicating vessels in gestations with twin-twin transfusion syndrome (TTTS) to test its association with neurological outcomes at approximately 2 years. METHODS: One-hundred children treated for TTTS with laser surgery underwent neurodevelopmental assessment at age 2 years (within 6 weeks) via the Battelle Developmental Inventory 2nd Edition (BDI-2). The CPR was obtained 24 h before and after laser surgery. An abnormal CPR was categorically defined at <1.0. Multilevel linear regression was used to evaluate associations between CPR and neurodevelopment as assessed by the BDI-2. RESULTS: Ninety-nine children had data available for analysis: 55 (56%) had normal CPR prior to laser surgery, and 62 (63%) had normal CPR following surgery. Post-laser CPR <1.0 was a risk factor for lower BDI-2 scores at age 2 years [98.1 (SD 11.5) vs 103.4 (SD 12.3) vs ß = -0.23, p = 0.01]; this relationship remained significant after controlling for pre-surgical CPR and Quintero stage (adjusted ß = -0.25, p = 0.01). CONCLUSIONS: In this population, an abnormal CPR was associated with poorer 2-year neurodevelopmental outcomes. © 2015 John Wiley & Sons, Ltd.

Blood pressure evaluation in children treated with laser surgery for twin-twin transfusion syndrome at 2-year follow-up.

OBJECTIVE: Twin survivors of twin-twin transfusion syndrome (TTTS) may be at risk for early onset of cardiovascular disease. The aim of this study was to determine prevalence and risk factors for elevated blood pressure (BP) among children treated with selective laser photocoagulation of communicating vessels. STUDY DESIGN: Data were prospectively collected from surviving children treated for TTTS with laser surgery from 2008 through 2010. Systolic BP (SBP) and diastolic BP (DBP) were obtained from 91 child survivors at age 24 months (±6 weeks) and evaluated based on age, sex, and height percentile. BP percentiles were calculated for each patient and categorized as normal (<95%) or abnormal (>95%). Clinical variables were evaluated using multilevel regression models to evaluate risk factors for elevated BP. RESULTS: BP was categorized as normal in 38% and abnormal in 62% of twin survivors based on percentile for sex, age, and height; a comparable distribution was found for DBP elevation. There were no differences between donor and recipient twins for absolute SBP and DBP or BP classification. In a multivariate analysis, significant risk factors for higher SBP included prematurity (ß -0.54; 95% confidence interval [CI], -0.99 to -0.09; P = .02), higher weight percentile (ß 0.24; 95% CI, 0.05-0.42; P = .01), and presence of cardiac disease (ß 0.50; 95% CI, 0.10-0.89; P = .01). Prematurity was also a significant risk for abnormal DBP (odds ratio, 0.89; 95% CI, 0.80-1.00; P = .05). CONCLUSION: Child survivors of TTTS had elevated SBP and DBP measurements at 2 years of age, with no differences seen between former donor and recipient twins. Prematurity may be a risk factor for elevated BP measurements in this population. Future studies are warranted to ascertain whether these cardiovascular findings persist over time.