Early infant neuromotor assessment is associated with language and nonverbal cognitive function in toddlers: the Generation R Study.

OBJECTIVE: Numerous studies in high-risk populations established that variations in infant neuromotor development predict poor cognitive function. It is unclear whether this association is found in the general population. Moreover, previous population-based studies mostly focused on motor milestone achievement. METHODS: This study was embedded in the Generation R Study, a population-based cohort in Rotterdam, the Netherlands. Neuromotor development was assessed with an adapted version of Touwen's Neurodevelopmental Examination when infants (1205 males, 1278 females) were on average 12 weeks old (standard deviation 1, range, 9-15 weeks). To measure language function at age 1.5 years, the MacArthur Short Form Vocabulary Checklist was used. At 2.5 years, mothers completed the Language Development Survey and the Parent Report of Children's Abilities measuring language and nonverbal cognitive functioning, respectively. RESULTS: After adjustment for confounders, less optimal neuromotor development, that is, more low tone symptoms, was associated with a delay in receptive language at 1.5 years (odds ratio [OR], 1.18; 95% confidence interval [CI], 1.05-1.34) and in expressive language at multiple time points (OR, 1.11; 95% CI, 1.02-1.21). Higher scores on overall neuromotor development, indicating a less optimal neuromotor development, was associated with an increased risk of a delay in nonverbal cognitive function at 2.5 years (OR, 1.19; 95% CI, 1.05-1.35). CONCLUSIONS: The results of this study suggest that infants with more low tone symptoms, indicating minor deviances from normal neuromotor development, are somewhat more vulnerable to language delays than those infants who do not have these symptoms.

Outcome at 4.5 years of children born after expectant management of early-onset hypertensive disorders of pregnancy.

OBJECTIVE: The objective of the study was to describe neurodevelopmental outcome at the age of 4.5 years in 216 children, born after expectant management of severe early-onset hypertensive complications of pregnancy. STUDY DESIGN: This was a prospective follow-up study until age 4.5 years from maternal admission onward. Developmental outcome measurements included child intelligence quotient and behavioral, motor, and neurological outcome. Abnormal composite outcome (perinatal mortality or abnormal developmental outcome) was studied in relation to gestational age (GA), birthweight (BW), and perinatal variables. RESULTS: Fetal and neonatal mortality was 9% and 8%, respectively. Of the 178 survivors, 149 (84%) were seen for follow-up. Mean GA was 31.4 weeks and 90% were born growth restricted. Abnormal developmental outcome occurred in 20% and abnormal composite outcome in 37%. CONCLUSION: Perinatal mortality or abnormal child development occurs in one third of pregnancies with early-onset and severe hypertensive complications and is highest in the lowest GA and BW ranges.

General movements in the perinatal period and its relation to echogenicity changes in the brain.

BACKGROUND: In preterm born infants abnormal general movements (GMs) generally normalize before three months post term, but may persist when perinatal brain injury is present. AIMS: To assess the continuity of GM quality from fetal to early neonatal period and its relation to brain echogenicity changes. STUDY DESIGN: Prospective study examining GMs and three vulnerable brain areas before and 7days after birth. The quality of GMs was classified as normal or abnormal by Gestalt-perception. The brain was examined for moderate echogenicity changes (periventricular: brighter than choroid plexus, intraventricular: filling equal or more than 50% of the ventricle, and locally increased basal ganglia/thalami). SUBJECTS: 94 fetuses from pregnancies complicated by preterm hypertensive disorders or labour at a gestational age between 26 and 34weeks. OUTCOMES MEASURES: Correlations of fetal GMs, echogenicity changes, and clinical parameters (e.g. gestational age, parity, hypertensive disorders or preterm labour, oligohydramnios and fetal growth restriction) with neonatal GMs. RESULTS: Fetal GMs were abnormal in 64%, normalizing in 68% within 7days after birth. Fetal GMs were significantly related to postnatal GMs (p=0.045). Moderate fetal brain echogenicity changes and clinical parameters were not significantly related to neonatal GM. CONCLUSIONS: In this population of pregnancies compromised by hypertensive disorders or preterm labour fetal GMs correlated with neonatal GMs. Presence of moderate echogenicity changes in the fetal brain was not related to neonatal GMs.

Fetal programming of infant neuromotor development: the generation R study.

The objective of the study was to examine whether infant neuromotor development is determined by fetal size and body symmetry in the general population. This study was embedded within the Generation R Study, a population-based cohort in Rotterdam. In 2965 fetuses, growth parameters were measured in mid-pregnancy and late pregnancy. After birth, at age 9 to 15 wks, neuromotor development was assessed with an adapted version of Touwen's Neurodevelopmental Examination. Less optimal neuromotor development was defined as a score in the highest tertile. We found that higher fetal weight was beneficial to infant neurodevelopment. A fetus with a 1-SD score higher weight in mid-pregnancy had an 11% lower risk of less optimal neuromotor development (OR: 0.89; 95% CI: 0.82-0.97). Similarly, a fetus with a 1-SD score larger abdominal-to-head circumference (AC/HC) ratio had a 13% lower risk of less optimal neuromotor development (OR: 0.87; 95% CI: 0.79-0.96). These associations were also present in late pregnancy. Our findings show that fetal size and body symmetry in pregnancy are associated with infant neuromotor development. These results suggest that differences in infant neuromotor development, a marker of behavioral and cognitive problems, are at least partly caused by processes occurring early in fetal life.

Maternal symptoms of anxiety during pregnancy affect infant neuromotor development: the generation R study.

Several studies found that maternal symptoms of anxiety or depression are related to functioning and development of the offspring. Within a population-based study of 2,724 children, we investigated the effect of maternal anxiety or depression on infant neuromotor development. Symptoms of anxiety and depression were measured during pregnancy and after giving birth; infant neuromotor development was assessed by trained research nurses during a home visit at the age of 3 months. The current study showed that mothers who were anxious during pregnancy had an elevated risk of having an infant with non-optimal neuromotor development.

Does gestational duration within the normal range predict infant neuromotor development?

AIM: To examine the extent to which infant neuromotor development is determined by gestational duration and birth weight within the normal range. METHODS: The study was embedded within the Generation R Study, a population-based cohort in Rotterdam, the Netherlands. An adapted version of Touwen's Neurodevelopmental Examination was used to assess 3224 infants (1576 males and 1648 females) at corrected ages between 9 and 15 weeks. Non-optimal neuromotor development was defined as a score in the highest tertile. RESULTS: Infant neuromotor development was significantly affected by gestational duration (odds ratio 0.8, 95% confidence interval 0.7;0.8). Adding a quadratic term of gestational duration to the model revealed a highly significant curvilinear association between gestational duration and neuromotor development; after adjusting for post-conceptional age this was still significant. Although babies with a 1 kg lower birth weight had a 30% higher risk of non-optimal neuromotor development, this association disappeared after adjustment for post-conceptional age. CONCLUSIONS: Our findings indicate that differences in infant neuromotor development can be explained even by variations in gestational duration within the normal range. If an infant is found to have minor neuromotor delays, account should be taken of this.

Functional outcomes and participation in young adulthood for very preterm and very low birth weight infants: the Dutch Project on Preterm and Small for Gestational Age Infants at 19 years of age.

OBJECTIVE: Young adults who were born very preterm or with a very low birth weight remain at risk for physical and neurodevelopmental problems and lower academic achievement scores. Data, however, are scarce, hospital based, mostly done in small populations, and need additional confirmation. METHODS: Infants who were born at < 32 weeks of gestation and/or with a birth weight of < 1500 g in The Netherlands in 1983 (Project on Preterm and Small for Gestational Age Infants) were reexamined at age 19. Outcomes were adjusted for nonrespondents using multiple imputation and categorized into none, mild, moderate, or severe problems. RESULTS: Of 959 surviving young adults, 74% were assessed and/or completed the questionnaires. Moderate or severe problems were present in 4.3% for cognition, 1.8% for hearing, 1.9% for vision, and 8.1% for neuromotor functioning. Using the Health Utility Index and the London Handicap Scale, we found 2.0% and 4.5%, respectively, of the young adults to have > or = 3 affected areas in activities and participation. Special education or lesser level was completed by 24%, and 7.6% neither had a paid job nor followed any education. Overall, 31.7% had > or = 1 moderate or severe problems in the assessed areas. CONCLUSIONS: A total of 12.6% of young adults who were born very preterm and/or with a very low birth weight had moderate or severe problems in cognitive or neurosensory functioning. Compared with the general Dutch population, twice as many young adults who were born very preterm and/or with a very low birth weight were poorly educated, and 3 times as many were neither employed nor in school at age 19.

Vestibulospinal component of postural control (vestibular function) in very preterm infants (25 to 27 weeks) at 3, 6, and 12 months corrected age.

Postural control, which is important for the development of all movement, balance, and locomotion, depends a great deal on the vestibulospinal component of vestibular function in early childhood. Vestibulospinal input is important for muscle power regulation, which, in turn, influences postural control. The aim of this study was to focus particularly on this component of vestibular function during the first year of life in 67 infants with a very short gestational age (25-27 weeks), to search for possible neonatal confounders, and to see whether it influences the course of muscle power development in preterm infants. Outcome was described as being optimal, suspect, or abnormal. The infants were categorized into the Neonatal Medical Index according to the severity of neonatal illness and separately into three groups for neonatal brain ultrasonography findings (normal to severe abnormalities). At the age of 3 months, 20 infants performed optimally on all items testing vestibular function, increasing to 40 at 6 months and 48 at 12 months. This significant improvement (also seen in muscle power regulation) was primarily caused by better head control (during the traction response and prone position), whereas less shoulder retraction and hyperextension were found in the sitting position. Vestibular function was significantly related to brain ultrasonography classification but not to gestational age, birthweight, the Neonatal Medical Index, or gender.

Muscle power development in preterm infants with periventricular flaring or leukomalacia in relation to outcome at 18 months.

Periventricular flaring (PVF) or periventricular leukomalacia (PVL) was diagnosed by brain ultrasound during the neonatal period in 44 infants (34 males, 10 females; mean gestational age 31 weeks 2 days, SD 2 weeks 1 day) admitted between 1995 and 1997. The infants were divided into three groups according to the severity of their condition. At 0, 3, and 6 months' corrected age an age-adequate neurological examination with special emphasis on the relation between active and passive muscle power was performed and symmetry between right and left sides was assessed. Results for the whole body, as well as for the shoulders, trunk, and legs were classified as optimal, suspect, or abnormal. Motor outcome at 18 months' corrected age was graded in the same way. An overall optimal muscle power regulation was found in one infant at 0, two at 3, and one at 6 months. Suspect outcome was found at all ages in the three groups. At 0 months muscle power regulation did not differ between the three groups. At 3 and 6 months overall poor muscle power, primarily caused by poor muscle power regulation in the shoulders and trunk, was found in infants with PVL grades III or IV. At 18 months' corrected age 24 infants showed no neurological impairment, eight infants had minor impairment, and 12 infants had severe impairment, including all 10 infants categorized as having PVL grades II or IV. The best predictors of impairment at 18 months were the combined results of muscle power in the shoulders and trunk at 3 months with those of the shoulders at 6 months.

Neuromotor function and school performance in 7-year-old children born as high-risk preterm infants.

Neuromotor behavior was studied in 63 children at a mean age of 7 years. They were born at a gestational age less than 32 weeks and/or birthweight under 1500 g and were categorized according to their medical history in conformance with the Neonatal Medical Index (from category I to V, from few to serious complications). We included only children considered at high risk as categorized in III to V. The neuromotor behavior study focuses on different subcategories, such as hand function, quality of walking, posture, passive muscle tone, coordination, and diadochokinesia. Hand preference and/or lateralization, the presence of associated movements, and/or asymmetry were noted, as was school performance. Then gender, gestational age, birthweight, and dysmaturity were investigated as confounding factors. The outcome at 7 years was correlated with the Neonatal Medical Index and the neonatal brain ultrasonography classification. None of the children scored 100% on the combined subcategories. Nineteen children (30%) had an overall score between 75 and 99%. Significant relationships between all different subcategories were found. Lack of hand preference, poor lateralization, and male gender were related to poor overall outcome. Poor motor control was correlated to special schooling and education below age level. The Neonatal Medical Index proved to have a significant influence on total outcome and the subcategories at the age of 7 years, with the worst outcome in children formerly classified in category V. Neuromotor behavior at 7 years of age was not related to birthweight, gestational age, dysmaturity, and neonatal brain ultrasonography classification only.

Muscle power development during the first year of life predicts neuromotor behaviour at 7 years in preterm born high-risk infants.

The aim of the study was to find if neurological function during the first year of life could predict neuromotor behaviour at 7 years of age in children born preterm with a high risk. A follow-up study of neuromotor behaviour in 52 children at a mean age of 3, 6, 12 months (corrected age) and 7 years was performed. All children were born with a gestational age less than 32 weeks and/or a birthweight under 1500 g and the infants were categorised according to their medical history in the three highest categories of the 'Neonatal Medical Index' (NMI, from category I to V, from few to serious complications). In addition, neonatal cerebral ultrasound abnormalities were used to divide the infants further into the different NMI categories. At 3 and 6 months, the relationship between active and passive muscle power was measured in shoulders, trunk and legs and (a)symmetry between right and left was noted. The results at 3 and 6 months were ranged from 1 for optimal to 5 for poor muscle power regulation. At 12 months of age, a neurological examination was done with special emphasis on the assessment of postural control, spontaneous motility, hand function and elicited infantile reactions with special attention to (a)symmetry. Outcome at 12 months was expressed as percentage of the optimal score on each subcategory. At 7 years, the motor behaviour study based on Touwen's examination for minor neurological dysfunction was performed. This investigation focuses on different functions, such as hand function, quality of walking, posture, passive muscle tone, coordination and diadochokinesis. The outcome was expressed as percentage of the optimal score on the combined subcategories. The best prediction of neuromotor behaviour at 7 years was assessed with stepwise linear multiple regression, using as potential predictors perinatal factors and outcome of motor behaviour at the corrected age of 3, 6 and 12 months. At 7 years none of the children scored 100% on the combined subcategories, 15 children (29%) scored between 75% and 99%, whereas 15 children scored less than 50%. Neuromotor behaviour at 7 years could be predicted by the NMI categorisation and gender with a sensitivity of 92% (specificity 47%; positive and negative predictive value 81% and 70%). No direct relation was found between neuromotor behaviour and cerebral ultrasound classification only, days on the ventilator and/or continuous positive airway pressure, birthweight, gestational age and dysmaturity. The best predictor of neuromotor behaviour at 7 years was the combination of outcome of muscle power in shoulders and legs at 3 months and postural control at 12 months, taking into account the gender of the child (sensitivity 95%; specificity 40%; positive predictive value 80%; negative predictive value 75%).

Transient dystonias revisited: a comparative study of preterm and term children at 2 1/2 years of age.

Minor neurological dysfunctions (MND) have frequently been reported as an outcome of preterm birth. Behavioural and learning difficulties are a known feature, but coordination problems are especially described in preterm infants at later ages. All preterm infants in our study were born with a gestational age of <32 weeks and a birthweight of <1500 g. The aim of the study was to determine if in a normal clinical situation, children at risk for developing coordination problems could be detected by focusing particularly on their spontaneous, although elicited, motor performance. Forty-two children of 2 years 6 months of age were studied of whom 25 were 'low-risk' preterm and 17 were born at term. All children had been followed up since birth. In a structured, free-field situation the quality of body rotation, spontaneous reaching-out, and manipulation during parts of the Bayley Developmental Test were observed and videotaped. Body rotations were scored on a 2-point scale, and arm and hand functions on a 3-point scale. Most preterm infants showed non-optimal body rotations and borderline or non-optimal arm and hand functions in contrast to most term children. A clear connection was found between less optimal body rotations and poor arm and hand functions. Retrospectively, poor arm and hand functions at 2 years 6 months seemed to be related to those at 39 weeks. At the age of 39 weeks a clear relation had been found between poor postural control (many preterm infants could not sit independently) and earlier hyperextension of the trunk at 18 weeks and quality of arm-hand functions. In the present study at 2 years 6 months a correlation with the former hyperextension could no longer be found, but there was a significant relation between poor trunk rotation and arm and hand function and the earlier arm and hand functions at 39 weeks.