Cognitive and neurologic development of the premature, small for gestational age infant through age 6: comparison by birth weight and gestational age.

OBJECTIVE: To compare the neurologic and cognitive outcomes of 129 premature small for gestational age (SGA) infants with 300 premature appropriate for gestational age (AGA) infants through 6 years of age. DESIGN: Infants born at < or = 37 weeks gestational age and < or = 2500 g with birth weight 2 standard deviations or more below the mean birth weight for gestational age were categorized as SGA. Cognitive and neurologic outcomes of SGA and AGA prematures at 1, 2, 3, and 5 and/or 6 years of age were compared when the infants were stratified by gestational age in 2-week intervals or by birth weight in 500-g intervals. The association between SGA/AGA and neurologic status on cognitive outcomes at each age was also examined. RESULTS: SGA infants had significantly poorer cognitive scores at each age when compared with AGA infants of similar gestational ages. Normal neurologic status was more likely at all assessments for the AGA than for SGA infants of comparable gestational age. There were no differences between SGA and AGA children in cognitive or neurologic outcomes at any age when grouped by birth weight. Cognitive impairment was closely associated with neurologic abnormality in both SGA and AGA groups. There was, nevertheless, a significant effect of SGA on cognitive outcome independent of neurologic status at all ages except 3 years. CONCLUSIONS: Irrespective of degree of prematurity, SGA infants are at greater risk for neurodevelopmental impairment than are equally premature AGA infants. The cognitive impairment can be largely, but not entirely, attributed to a higher incidence of neurologic abnormalities in the SGA infants at each gestational age.

Preventive interventions with low birth weight premature infants: an evaluation of their success.

The outcome literature on low birthweight (LBW) premature children indicates that they are at risk for a variety of neurodevelopmental impairments throughout childhood. To prevent such disabilities, numerous interventions have been initiated with LBW children. Nineteen intervention programs designed for LBW preterms that have published study results dating from 1971 are reviewed. Included are interventions in the neonatal nursery, at home, and at centers as well as interventions that are both child-focused and parent-focused. One randomized clinical trial evaluating comprehensive intervention services, the Infant Health and Development Program, is described in detail. Conclusions from the studies reviewed indicate that intervention programs have had only modest success in altering neurodevelopmental outcomes, although parent-child interaction has often been facilitated. Future research on the effects of preventive intervention needs to examine long-term developmental competencies and to replicate positive findings in multiple settings.

Early otitis media and phonological development at age 2 years.

The effect of early otitis media on phonology and articulation in the presence of expressive language delay was investigated in 16 2-year-olds followed prospectively from birth. Eight of the children were designated otitis-positive and 8 were considered otitis-negative as determined by bilateral pneumatic otoscopy outcomes during year 1 of life. The groups differed significantly on measures of expressive, not receptive, language development. All members of the otitis-positive group were expressive language delayed. Phonological analyses were completed on spoken language samples elicited from each child at age 24 months. Results showed similar developmental tendencies in speech sound acquisition between the groups, but the otitis-positive group had established significantly fewer initial consonant phones and produced them less accurately than the otitis-negative subject group. The otitis-positive group acquired significantly fewer consonants with back place of articulation. Similar phonological error patterns of deletion and phoneme class deficiency were used by the groups, but the otitis-positive group used the error patterns more frequently. Findings here lend support to the otitis media effect as one of interaction among risk factors.

Otitis media, auditory sensitivity, and language outcomes at one year.

The relationship among otitis media, auditory sensitivity, and emerging language was examined in a group of 1-year-old children who were prospectively followed since birth. Pneumatic otoscopy was used to document the otologic status of the children's ears at each medical visit. There were 13 babies with normal ratings in each ear at 80% more of their visits (designated as "otitis free") and 12 babies with bilaterally positive otoscopy results at 30% or more of their first year visits (designated "otitis positive"). In comparison to the otitis free infants, the group of otitis positive babies demonstrated reduced auditory sensitivity as measured by auditory brain stem response (ABR) and poorer expressive language abilities. However, differences in receptive language were not detected. These results suggest that otitis media may have an impact on auditory sensitivity and developing language as early as 1 year of age.

Relations between infant neurobehavioral performance and cognitive outcome in very low birth weight preterm infants.

The predictive utility of three aspects of neonatal neurobehavioral performance was examined in 144 very low birth weight (< 1500 g) preterms who were followed until 6 years of age. Visual-following and auditory-orienting composites derived from the Einstein Neonatal Neurobehavioral Assessment Scale were modestly related to the Mental Developmental Index (MDI) and IQ scores at several ages, whereas the active motility composite was only related to MDI scores at 1 year of age (corrected). Infants who showed deviant performance on both visual following and auditory orienting composites had significantly lower cognitive test scores at 1 and 6 years of age and were more likely to be classified as subaverage at 6 years of age (IQ < 85). Group differences were independent of both neonatal health status and motor scores and were not due to the performance of children with severe sensory impairments. These findings suggest that visual following and auditory orienting measured in the neonatal period can offer a useful way of indexing initial capacities.

Otitis media, communication style of primary caregivers, and language skills of 2 year olds: a preliminary report.

The association between early otitis media, styles of primary caregivers, and language development was prospectively examined in 26 2-year-old children from lower socioeconomic backgrounds (of mixed perinatal status) followed prospectively since birth. Based on otoscopic evaluations during the first year of life, there were 14 children who were classified as bilaterally otitis-free (OM-) and 12 children who were classified as bilaterally otitis-positive (OM+). At 2 years of age, all children were administered standardized measures of cognitive and language function along with a 20-minute videotaped play session with one of their primary caregivers. The language of both the children and caregivers was analyzed. Results indicate that caregivers of OM+ and OM- children used language nearly identically when interacting with their children. However, caregivers of OM+ children whose communication style was marked by a high percentage of directives and a corresponding low percentage of both questions and information-giving had the children with the lowest scores on all measures of naturalistic language. Controlling for neonatal illness did not alter the relationships found. The results suggest that caregiver language may compensate for some of the auditory deprivations associated with otitis media.

Long-term communication deficiencies in children with otitis media during their first year of life.

A cohort of lower socio-economic children who experienced multiple episodes of otitis media (OM) during their first year of life were compared to a group of children who were largely free of OM during their first year. Both groups were followed until 9 years of age. The data indicate that some children with positive histories of OM performed poorer on a variety of communicative tasks across the 9 year age span than the children with the negative histories of OM. The results suggest that the effect of otitis media and its accompanying hearing loss on communication skills may extend throughout childhood.

Early otitis media and later educational risk.

Fourteen children aged 6 years received screening for educational risk status and formal measures of academic performance. These children have been followed prospectively from birth for their otitis media status. Seven of the children were considered positive for otitis media in year one (recurrent episodes bilaterally), while 7 were considered otitis free. Academic status was related to early hearing acuity (as determined by repeated ABR assessment). Moreover, teachers' ratings of academic risk status were related to a measure at 4 years that examined the children's capacity to listen in background noise.

Auditory consequences of early mild hearing loss associated with otitis media.

Two groups of children received periodic documentation of their middle ear status by pneumatic otoscopy in the first year of life and had hearing sensitivity estimated by multiple auditory brainstem response (ABR) assessments during the same period. One group was considered otitis media (OM)-positive, with repeated bilateral episodes of OM and mild conductive hearing loss. The second group was considered OM-free with normal middle ear function bilaterally and normal hearing sensitivity in the first year of life. Children's higher-order auditory abilities were examined at 4, 6 and 9 years of age. Various measures such as speech recognition-in-competition, visual-auditory learning, sound blending, auditory memory, and masking level difference estimates were utilized to probe the children's auditory abilities. Results show that children with a first-year history of otitis media demonstrate deficits in the long term in some aspects of higher-order auditory processing. Performance appears to be associated with the mild hearing loss experienced during an important period of early development.

Effects of otitis media with effusion on hearing in the first 3 years of life.

Hearing sensitivity was examined prospectively in young children as a function of otitis media with effusion (OME) status in Years 1, 2, and 3. Hearing and OME status were sampled bimonthly from 5 to 36 months of age. Behavioral thresholds were obtained at 4 test frequencies (500, 1000, 2000, and 4000 Hz) using visual reinforcement audiometry and conditioned play audiometry techniques. The majority of children's audiograms were obtained using a computer-controlled test procedure. Thresholds for the test frequencies were averaged for each visit and then averaged across all visits in each year. Reference values were developed for infants and children in Years 1, 2, and 3 who were OME free. Results reveal that children who were classified as bilaterally OME positive in Years 1, 2, and 3 had significantly poorer hearing than children classified as bilaterally OME free in each of these time periods. There was no difference in hearing as a function of gender, socioeconomic status, or birth-risk status.

Interactions of African American infants and their mothers: relations with development at 1 year of age.

The relationships between aspects of mother-infant interaction and both communication and cognitive skills at 1 year of age were examined in 92 African American dyads, of whom 64 (70%) fell below the poverty line. Ratings of warmth, sensitivity, responsiveness, encouragement of initiative, stimulation, and elaborativeness during a semistructured play interaction were correlated with measures of global cognition, expressive and receptive communication, and communication use. The overall quality of the home environment and maternal ratings of stimulation and elaborativeness were the most consistent correlates of infant communication measures. Relationships were stronger in middle-income than lower-income dyads. These results support the linkage of didactic and functional aspects of maternal behavior to cognitive and communication skills at 1 year of age for African American infants.

Visual recognition memory: a predictor of later cognitive functioning in preterms.

A number of preterms who had participated in a study of visual recognition memory when they were 6 months of age were seen at older ages to assess the predictive validity of the early visual measures for cognitive outcome. The Bayley scales were administered at 6, 12, and 24 months, the Stanford-Binet at 34 and 40 months, and the WISC-R at 6 years. Novelty scores, which reflect the relative amount of time infants look at new compared to familiar stimuli, constituted the measure of infant visual processing. These scores, obtained by averaging over performance on the 3 or 4 problems administered at 6 months of age, were consistently and significantly related to cognitive measures from 24 months to 6 years, with correlations ranging from r = .53 to r = .66. Parental education, which was unrelated to novelty scores, bore a strong relationship to outcome beginning at 24 months. Although both measures contributed uniquely to the variance in cognitive outcome at 24 months and 6 years, visual novelty scores made a stronger contribution than did parental education. Neither 6- nor 12-month Bayley scores, nor various perinatal variables, were related to outcome.

Language, speech, and educational outcomes of otitis media.

OBJECTIVE: This article, through a summary of the current literature available, studies the relationship between recurrent otitis media (OM) and communication (speech and language) and educational development. Areas discussed include historical and current views of their relationship, hearing loss and auditory abilities, language and speech development, and educational (cognitive and academic) performance of children with histories of OM. As well, the authors present a model for the use of physicians, communications specialists, and educators when dealing with such children. CONCLUSION: Despite significant advances in our understanding of OM-related communication and educational development, more prospective studies that also consider the role of other mediating and moderating variables affecting language in children with OM histories are needed.

Listening and language at 4 years of age: effects of early otitis media.

The effect of early otitis media on preschoolers' listening and language abilities was examined in a cohort of prospectively followed children. At 4 years of age, children considered otitis negative and otitis positive during the first year of life were examined using a speech-in-competition task and several standardized measures of language and cognitive function. An adaptive test procedure was used, with sentence materials from the Pediatric Speech Intelligibility Test (PSI) (Jerger & Jerger, 1984). Results indicated that children with positive histories of otitis media during the first year required a more advantageous signal-to-competition ratio to perform at 50% sentence intelligibility than did their otitis-negative peers. There was no interaction between birth status (high-risk or full-term) and adaptive PSI listening task outcome. No differences between the groups were found in either receptive or expressive language abilities or in cognitive abilities. Further, there was no relationship between any language or cognitive measure and the adaptive PSI result.

Infant information processing in relation to six-year cognitive outcomes.

As part of a longitudinal follow-up of full-terms and preterms, infant measures of information processing obtained at 7 months and 1 year were related to various 6-year outcomes: general intelligence, language proficiency, early reading and quantitative skills, and several facets of perceptual organization (N = 91). 7-month Visual recognition memory (VRM) was associated with 6-year performance in all domains, and 3 1-year measures--VRM, cross-modal transfer (CMT), and object permanence--were related to IQ and/or one or more specific outcomes (r's = .20 to .47). Many of the infant-childhood relations remain significant even with IQ partialed. Additionally, 7-month VRM and 1-year CMT scores were lower for infants who, at 6 years, were considered at risk for learning disabilities. Overall, measures from the first year of life predicted both specific cognitive abilities and IQ at 6 years; to some extent, the specific abilities were predicted independently of IQ.

Individual differences in infants' information processing: reliability, stability, and prediction.

A group of 46 full-term and 54 high-risk preterm (less than 1,500 grams birthweight) infants were tested at 6, 7, and/or 8 months of age (corrected age for preterms) on a battery of problems assessing visual recognition memory and tactual-visual cross-modal transfer. At all 3 ages, scores obtained on aggregates of 6-11 problems in the battery significantly predicted 3-year Stanford-Binet IQ: correlations ranged from r = .37 to r = .63, and clustered between r = .50 and r = .60. When aggregates from 2 or 3 ages were used as predictors, multiple correlations were as high as R = .60 and R = .70. Cutoffs for predicting children at risk for mental retardation (IQ less than 70) or cognitive delay (IQ less than 85) showed reasonable sensitivity and specificity, although low scores were poor at detecting IQs less than 70. The internal consistency of composites, indexed by alpha coefficients, was unexpectedly low, primarily because the problems shared little variance. However, stability coefficients between assessments as much as 1 and 2 months apart were moderate in magnitude, ranging from r = .30 to r = .50. Considering the high degree of predictive validity, the stability figures appear to be better estimates of reliability for these measures than are indices of internal consistency. The relations reported here were similar for both full-terms and preterms.

Early intervention for low-birth-weight premature infants: what can we achieve?

Low-birth-weight (LBW) premature infants are at increased risk for abnormal development. It is unclear whether intervention programs designed to prevent the disabilities in preterm children are efficacious. This paper reviews the settings in which interventions take place (e.g. nursery, home) and to whom they are directed (e.g. infant, parent). One intervention program, the Infant Health and Development Program (IHDP) is reviewed in detail. The IHDP was a multisite randomized clinical trial to evaluate the efficacy of combining developmental and support services along with paediatric follow-up to reduce the developmental problems seen among LBW preterm infants. Results from all studies suggest that preventive developmental interventions for LBW, premature infants have thus far demonstrated only modest success. Future research endeavours should investigate the type, duration, critical age onset, and intensity of the intervention as well as which subgroups of LBW infants most benefit from such programs.

Otitis media and language development at 1 year of age.

The effect of otitis media on emerging language was examined in a group of 1-year-olds. Based on pneumatic otoscopy, 15 babies were considered to be free of otitis media in both ears at 80% or more of their first year medical visits (otitis free) and 12 infants had bilaterally positive otoscopy results at 30% or more of their visits (otitis positive). Outcome measures at 1 year included the Bayley Scales of Infant Development (Bayley, 1969) and the Sequenced Inventory of Communication Development (SICD; Hedrick, Prather, & Tobin, 1984) Receptive and Expressive scales. No significant differences were detected on either the Bayley or the SICD Receptive scale. However, the otitis positive group exhibited significantly lower expressive language scores than the otitis free group, suggesting that impairments in language expression may be evident as early as 1 year of age in children with otitis media.

Results at age 8 years of early intervention for low-birth-weight premature infants. The Infant Health and Development Program.

OBJECTIVE: To reevaluate at age 8 years children who had participated during the first 3 years of life in a randomized clinical trial of special services for low-birthweight (LBW) premature infants. DESIGN: Follow-up of a randomized controlled trial of premature infants (< or = 37 weeks' gestation), stratified by 2 LBW groups (lighter [< or = 2000 g] and heavier [2001-2500 g]) and divided into intervention (n=377) and follow-up only (n=608) groups. SETTING: Eight sites serving diverse populations. PARTICIPANTS: At age 8 years, 874 children were assessed: 336 in the intervention group and 538 in the follow-up only group. INTERVENTION: The 3-year intervention consisted of home visits (birth to 3 years), child development center services (ages 1 to 3 years), and parent group meetings (ages 1 to 3 years). PRIMARY OUTCOME MEASURES: Cognitive functioning (Weschler Intelligence Scale for Children-III; Peabody Picture Vocabulary Test-Revised); academic achievement (Woodcock-Johnson Tests of Achievement-Revised); and parental reports of school performance, behavior (Child Behavior Checklist), and health (Child General Health Survey). RESULTS: At age 8 years, in the entire cohort and in the lighter LBW stratum, the intervention and follow-up only groups were similar on all primary outcome measures. Differences favoring the intervention group were found within the heavier LBW group: full-scale IQ score (4.4 points higher, P=.007), verbal IQ score (4.2 points higher, P=.01), performance IQ score (3.9 points higher, P=.02), mathematics achievement score (4.8 points higher, P=.04), and receptive vocabulary score (6.7 points higher, P=.001). On a physical functioning subscale, the whole intervention group received less favorable ratings, while the lighter LBW intervention group had lower maternal ratings assessing social limitations caused by behavior. CONCLUSION: Although at age 8 years there were modest intervention-related differences in the cognitive and academic skills of heavier LBW premature children, attenuation of the large favorable effects seen at 3 years was observed in both the heavier and lighter LBW groups. This indicates a need to develop additional intervention strategies for LBW premature children that can provide sustained benefits.