Establishing Bayley-III cut-off scores at 21 months for predicting low IQ scores at 3 years of age in a preterm cohort.

OBJECTIVE: To evaluate predictive validity and establish cut-off scores on the Bayley-III at age 21 months that best predict Intelligence Quotient (IQ) scores <70 or <80) at 3 years in a high-risk preterm cohort. METHOD: Bayley-III evaluations at 21 months corrected age and intellectual assessments, primarily with the WPPSI-III, at 3 years corrected age were conducted with 520 infants born less than 29 weeks gestational age or less than 1250 g birth weight. Receiver Operator Characteristic (ROC) curves were used to establish Bayley-III Cognitive Composite cut-off scores that maximized Sensitivity and Specificity in predicting low IQ. Similar analyses were performed using the Language Composite, and a research derived mean Cognitive-Language Composite. RESULTS: A regression model for the association between 21-month Bayley-III Cognitive Composite and 3-year IQ scores was significant (P<0.0001, Adjusted R2=0.36). The ROC area under the Curve was 0.90 for the Cognitive Composite predicting IQ<70. The cut-off score that maximized Sensitivity and Specificity for predicting 3-year IQ<70 was a Cognitive Composite of <80. The ROC Area under the Curve was 0.80 for Cognitive Composites predicting IQ<80 and a Cognitive Composite cut-off score of <90 maximized Sensitivity and Specificity. CONCLUSION: In this high-risk preterm cohort, there was a strong association between the Bayley-III Cognitive Composite at 21 months and IQ at 3 years. A Cognitive Composite cut-off score of <80 optimized classification of IQ<70 at 3 years, and a Cognitive Composite cut-off score of <90 optimized classification of IQ<80.

Neurotoxicity of sedative and analgesia drugs in young infants with congenital heart disease: 4-year follow-up.

OBJECTIVES/AIM: To determine whether sedation/analgesia drugs used before, during, and after infant cardiac surgery are associated with neurocognitive and functional outcomes. BACKGROUND: Some animal models suggest neurotoxic effects of anesthetic drugs on the developing brain; however, potential human effects are unknown. Whether these results can be extrapolated to humans is unknown. METHODS/MATERIALS: Prospective follow-up project of all infants ≤6 weeks old having surgery for congenital heart disease between 04/03 and 12/06. Demographic, perioperative, and sedation/analgesia variables were collected. Outcomes at kindergarten age were Wechsler Preschool and Primary Scale of Intelligence-III, Beery-Buktenica Developmental Test of Visual Motor Integration (VMI-V), and General Adaptive Composite (GAC) of the Adaptive Behavior Assessment System-II. Multivariable linear regression was used to identify predictor variables. RESULTS: From 135 infants who underwent heart surgery, 19 died, 17 were excluded, 8 were lost to follow-up, leaving 91 children for analysis. Multiple linear regression found days on chloral hydrate [3.5 (3.7) days] was associated with lower performance intelligence quotient (PIQ) (Effect size -1.03; 95% CI -1.96, -0.10; P = 0.03), and cumulative dose [54.2 (60.3) mg·kg(-1) ] of benzodiazepines was associated with lower VMI scores (Effect size -0.07; 95% CI -0.12, -0.01; P = 0.026). No other associations were found between sedation/analgesia variables and full-scale IQ, PIQ, Verbal IQ, VMI, or GAC. CONCLUSION: Assessment of this cohort at kindergarten age found a small statistically significant association between days on chloral hydrate and PIQ, and benzodiazepine cumulative dose and lower VMI. No other association between sedation/analgesia drugs and outcomes was found.

Neurodevelopmental outcome following exposure to sedative and analgesic drugs for complex cardiac surgery in infancy.

OBJECTIVES/AIM: To determine whether sedation/analgesia drugs used before, during, and after infant cardiac surgery are associated with neurodevelopmental outcome. BACKGROUND: Animal models suggest detrimental effects of anesthetic drugs on the developing brain. Whether these results can be extrapolated to human neonates is unclear. METHODS/MATERIALS: This is a prospective follow-up project conducted in Western Canada. In all infants ≤6 weeks of age having surgery for congenital heart disease between April 2003 and December 2006, demographic and perioperative variables were collected prospectively. Sedation/analgesia variables were collected retrospectively. For each drug class (inhalationals, opioids, benzodiazepines, ketamine, and chloral hydrate), we calculated the cumulative dose received during hospitalization, average dose received per day, and cumulative number of days the patient received the drug. The outcomes at 18-24 months were as follows: General Adaptive Composite and motor scaled scores of the Adaptive Behavior Assessment System, significant mental, motor, and vocabulary delay. Multivariable logistic and linear regression was used to analyze the data. RESULTS: One hundred and thirty-five neonates underwent open heart surgery; 19 died, 16 had chromosomal abnormality, and five were lost to follow up, leaving 95 survivors for analysis. Multiple linear regression analysis found no evidence of an association between sedation/analgesia variables and ABAS-GAC score or motor scale score. Multiple logistic regression analysis found no evidence of an association between sedation/analgesia variables and significant mental, motor, or vocabulary delay. CONCLUSION: We found no evidence of an association between dose and duration of sedation/analgesia drugs during the operative and perioperative period and adverse neurodevelopmental outcomes.

Assessment of developmental coordination disorder in children born with extremely low birth weights.

There is no tool that is considered the "gold" standard for identifying children with developmental coordination disorder (DCD) and various techniques have been reported in the research literature. The aim of this study was to examine the prevalence of DCD in a cohort of extremely low birth weight (ELBW; birth weight ≤ 1,000g) children at age 5 years using various methods including standardized motor assessment measures, an established clinic protocol, and a parent report. We also examined the association between selected neonatal risk factors and severity of the motor impairment. Four methods were used to assess motor functioning: (1) the Movement Assessment Battery for Children (Movement ABC); (2) a motor assessment battery, which included the Movement ABC, the Beery-Buktenica Developmental Test of Visual Motor Integration, and the Developmental Test of Visual Perception-2; (3) a Perinatal Follow-up Clinic protocol, which included the Geometric Design and the Mazes subtests of the Wechsler Preschool and Primary Scale of Intelligence-Revised, the Fine and Gross Motor subscales of the Child Development Inventory, and a pediatric neuromotor exam; and (4) a parent completed questionnaire (i.e., Developmental Coordination Disorder Questionnaire (DCDQ)). The prevalence of motor impairment in ELBW children was 64% on the Movement ABC, 67% on the motor assessment battery, 66% on the Perinatal Follow-up Clinic protocol, and 26% on the DCDQ. Sensitivity ranged from 36% to 100% and specificity from 65% to 92% using the Movement ABC as the reference standard. Neonatal risk factors associated with increased severity of motor impairment were bronchopulmonary dysplasia, postnatal steroids, and increasing gestational age. Children with birth weights ≤ 1,000 g are at considerable risk for motor impairment; therefore, developmental evaluations should include an assessment of motor functions. A standardized motor assessment test such as the Movement ABC appears to be the most effective and efficient means of identifying motor impairment in this high-risk population.

Overestimating neurodevelopment using the Bayley-III after early complex cardiac surgery.

BACKGROUND: The newest measure of neurodevelopmental outcomes, the Bayley Scales of Infant and Toddler Development, 3rd Edition (Bayley-III), gives higher-than-expected scores for preterm infants; results after cardiac surgery are unknown. OBJECTIVES: The goal of this study was to report Bayley-III scores after cardiac surgery and compare the results with those of the Bayley Scales of Infant Development, 2nd Edition (BSID-II) on a subset of the same children. METHODS: In this prospective, inception cohort, neurodevelopmental outcome study after complex cardiac surgery in infants from 2004 to 2007, the Bayley-III was given to 110 survivors (68% boys) at a mean age of 21 months (SD: 4 months). Analysis of variance was used to compare intergroup differences. Results for both test editions on the same 25 children were compared by using paired-samples statistics. RESULTS: Mean (SD) Bayley-III mean composite scores (CSs) for 110 children were as follows: cognitive, 95.9 (14.1); language, 90.8 (18.1); and motor, 93.7 (14.2), differentiating selected cardiac surgery groups. The average difference in mean CSs was 7.4 points higher than BSID-II scores for a previous cohort from this site and 7.2 points higher than a systematic review report. Direct comparison of BSID-II and Bayley-III revealed an average difference in mean CSs of 6.1 points, similar to normative results. Mean cognitive CSs increased by 10.0 (P <.001), language by 1.4 (P = .526), and motor by 6.9 points (P = .009). CONCLUSIONS: Researchers should be careful attributing higher Bayley-III scores to changes in acute care. At-risk children who previously qualified for early developmental intervention may no longer do so. School-age longitudinal studies are needed to determine the accuracy of early developmental estimates using the Bayley-III.

Five-year neurocognitive and health outcomes after the neonatal arterial switch operation.

OBJECTIVES: We sought to assess the 5-year neurocognition and health of an interprovincial inception cohort undergoing the arterial switch operation for transposition of the great arteries. METHODS: Sixty-nine consecutive neonates had operations from 1996-2003 with full-flow cardiopulmonary bypass and selective deep hypothermic circulatory arrest. Outcomes were recorded at 58 +/- 9 months of age. Univariate and multivariate analyses were used to identify outcome predictors, including surgical subtype and preoperative, operative, and postoperative variables. RESULTS: There was 1 (1.5%) operative death. Two children were lost to follow-up, and 1 was excluded because of postdischarge meningitis. Outcomes are reported for 65 survivors. Two (3%) children have cerebral palsy, and 7 (11%) have language disorders, 4 of whom also meet the criteria for autism spectrum disorder. Two of the 4 children with autism have an affected older sibling. Of the 61 children without autism, scores approach those of peers, with a full-scale intelligence quotient of 97 +/- 16, a verbal intelligence quotient of 97 +/- 18, a performance intelligence quotient of 96 +/- 15, and a visual-motor integration score of 95 +/- 16. Mother's education, birth gestation or weight, and postoperative plasma lactate values account for 21% to 32% of the variance of these scores. Septostomy adds 7% to the variance of visual-motor integration scores. CONCLUSIONS: Most preschool children do well after surgical correction for transposition of the great arteries, including complex forms. Potentially modifiable variables include high preoperative plasma lactate levels and septostomy. A minority of children were given diagnoses of language disorders, including autism, in which familial factors likely contribute to outcome.

Neurocognitive, functional, and health outcomes at 5 years of age for children after complex cardiac surgery at 6 weeks of age or younger.

OBJECTIVE: This work provides neurocognitive, functional, and health outcomes for 5-year survivors of early infant complex cardiac surgery, including those with chromosomal abnormalities. PATIENTS AND METHODS: Of 85 children (22.4% mortality), 61 received multidisciplinary, individual evaluation and parental questionnaires at 5 years. Full-scale, verbal, and performance IQ scores were compared by using analysis of variance among children who received different surgeries (arterial switch, 20; Norwood for hypoplastic left heart syndrome, 14; simple total anomalous pulmonary venous connection, 6; miscellaneous, 21; and chromosomal abnormalities, 8). Predictions from mental scores at 2 years for IQ scores at 5 years were determined. RESULTS: Children with chromosomal abnormalities had lower full-scale and verbal IQs at 5 years than other survivors, with no differences found among the remaining groups. For children post-Norwood, performance IQ scores remained lower than for children after the arterial-switch operation. Prediction of full-scale IQ (<70) from 2-year mental scores for all 61 children were as follows: sensitivity, 87.5%; specificity, 88.1%; positive predictive value, 53.8%; and negative predictive value, 97.9%. For full-scale IQ of <85, predictions were 90.0%, 87.8%, 78.3%, and 94.7%, respectively. For those 53 without chromosomal abnormalities, full-scale IQ <70, respective predictions were 86.7%, 90.0%, 28.6%, and 97.8%, and for full-scale IQ <85, respective predictions were 85.7%, 89.7%, 75.0%, and 94.6%. Parental report indicated good health in 80% and adequate function in 67% to 88% of the children, although health-utilization numbers suggest that these reports are optimistic. CONCLUSIONS: Five-year full-scale and verbal IQs were similar among groups, excluding those with chromosomal abnormalities. Children with chromosomal abnormalities had the lowest scores. Excluding those with chromosomal abnormalities, the mean mental scores for the children as a group tended to increase from 2 to 5 years of age, with an overall high percentage of correct classifications at 2 years.