Implementation of remote general movement assessment using the in-motion instructions in a high-risk norwegian cohort.

BACKGROUND: General Movement Assessment (GMA) is recommended for early detection of risk for cerebral palsy but requires trained clinical experts. We aimed to implement home- and hospital-based filming for remote GMA in a Norwegian high-risk infant cohort, as well as evaluating parents' experiences in filming their infant at home. METHODS: This knowledge translational study used a prospective cohort design including participants referred to neurodevelopmental follow-up across three sites in the Central Norway Regional Health Authority. Two home films of the fidgety type of general movements were collected between 12+1-14+6 and 15+1-17+6 weeks after term by parents. An additional film was collected at the hospital between 12+1 and 17+6 weeks after term. The instructional guide for all filming was the In-Motion App standards. Videos were transferred to a remote GMA team and classified as either "GMA scorable" or "GMA not scorable" based on Prechtl's GMA standards. Parents responded to an online survey using a 5-point Likert scale to collect information about their perspectives, experiences, and possible worries by filming their infant at home. RESULTS: One-hundred-and-two infants from 95 families participated. Ninety-two (96.8%) families transferred 177 home-based videos. Eighty-four (92%) of these had 95 videos taken in their local hospital. All 177 home-videos were "GMA scorable" and three (3,1%) out of 95 hospital-based videos were classified as "GMA not scorable". Eight families did not respond to the survey and two families did not receive the survey due to a technical error. Seventy-eight (91.7%) respondents agreed or strongly agreed that it was easy to perform home filming and five (5.9%) agreed that they were more worried about their child`s development after filming at home. Almost 80% of respondents agreed that a video for GMA can be taken at home instead of in hospital. CONCLUSIONS: This study strengthens the clinical implementation of home filming by parents and remote GMA for early detection of CP in high-risk follow-up programs. The implementation of remote GMA has the potential to facilitate early intervention to improve function in children with CP in line with international recommendations. TRIAL REGISTRATION: ClinicalTrials.gov ID: NCT04287166 Date of registration: 27/02/2020.

Inter-rater reliability of the Silverman and Andersen index-a measure of respiratory distress in preterm infants.

BACKGROUND: There are various methods of respiratory support available to optimize respiratory function in preterm infants. Respiratory scoring tools might provide information on which method to choose and the level and duration of support needed. Before implementing a respiratory scoring tool in our clinical practice, we aimed to test the inter- and intra-rater reliability of the Silverman and Andersen index (SA index) among neonatologists and nurses when applied to preterm infants on respiratory support. We also examined the association between the SA index and the electrical activity of the diaphragm (Edi signals). METHODS: This was a multicenter study including three newborn intensive care units in Norway. Four neonatologists and 10 nurses applied the SA index when assessing 80 videos of 44 preterm infants on High Flow Nasal Cannula, Continuous Positive Airway Pressure and Neurally Adjusted Ventilatory Assist. The inter- and intra-rater reliability for the sum scores were measured by the intra-class correlation coefficient (ICC), and Kendall's W was used to assess the degree of agreement for each item. We quantified the association between the Edi signals and the SA index scores by the Spearman's correlation coefficient. RESULTS: We found poor inter-rater reliability with an ICC for absolute agreement of 0.34 (95% CI: 0.20 to 0.53). There was fair agreement measuring each item separately for upper chest movements (Kendall's W 0.30), and moderate for lower chest movements (0.43) and xiphoid retractions (0.44). Expiratory grunting showed substantial agreement (0.67). The intra-rater reliability was good (ICC for absolute agreement 0.77; 95% CI: 0.68 to 0.84). We found a moderate positive correlation (r = 0.468, p = 0.028) between the maximum inspiratory diaphragm activity (Edi peak) and the mean inspiratory SA index scores. CONCLUSION: Our study showed poor inter-rater and good intra-rater reliability of the SA index when nurses and neonatologists assessed videos of preterm infants on various types of respiratory support. Edi peak and SA index had a moderate positive correlation. Formal training might be essential to improve the inter-rater reliability. TRIAL REGISTRATION: Registered 26th June 2017, ClinicalTrials.gov Identifier: NCT03199898.

A randomised cross-over study showed no difference in diaphragm activity during weaning from respiratory support.

AIM: We measured electrical activity of the diaphragm (Edi) to compare the breathing effort in preterm infants during weaning from respiratory support with high-flow nasal cannulae (HFNC) or nasal continuous positive airway pressure (nCPAP). METHODS: This randomised cross-over study was carried out at St Olav's University Hospital, Trondheim, Norway, from December 2013 to June 2015. We gave 21 preterm infants weighing at least 1000 g HFNC 6 L/minute for four hours and nCPAP 3 cmH2 O for four hours with a one-hour wash-out period. Measurements included diaphragmatic load, Edi, vital signs and a modified Silverman-Andersen Retraction Score. RESULTS: We found no differences in HFNC and nCPAP in the median Edi peak (8.0 µV versus 7.8 µV, p = 0.095), median Edi min (1.1 µV versus 1.2 µV in, p = 0.958) or mean heart rate (157 versus 159, p = 0.300) in the 21 infants who took part. The mean respiratory rate was significantly lower during HFNC than nCPAP (47 versus 52, p = 0.012). The modified Silverman-Andersen Retraction Score showed no significant differences. CONCLUSION: This study of preterm infants found no difference in the breathing effort measured by Edi between HFNC 6 L/minute and nCPAP 3 cmH2 O. HFNC could replace nCPAP when preterm infants are ready for weaning.

Limited microstructural and connectivity deficits despite subcortical volume reductions in school-aged children born preterm with very low birth weight.

Preterm birth and very low birth weight (VLBW, ≤1500 g) are worldwide problems that burden survivors with lifelong cognitive, psychological, and physical challenges. In this multimodal structural magnetic resonance imaging (MRI) and diffusion MRI (dMRI) study, we investigated differences in subcortical brain volumes and white matter tract properties in children born preterm with VLBW compared to term-born controls (mean age=8 years). Subcortical brain structure volumes and cortical thickness estimates were obtained, and fractional anisotropy (FA), mean diffusivity (MD), radial diffusivity (RD), and axial diffusivity (AD) were generated for 18 white matter tracts. We also assessed structural relationships between white matter tracts and cortical thickness of the tract endpoints. Compared to controls, the VLBW group had reduced volumes of thalamus, globus pallidus, corpus callosum, cerebral white matter, ventral diencephalon, and brain stem, while the ventricular system was larger in VLBW subjects, after controlling for age, sex, IQ, and estimated total intracranial volume. For the dMRI parameters, group differences were not significant at the whole-tract level, though pointwise analysis found shorter segments affected in forceps minor and left superior longitudinal fasciculus - temporal bundle. IQ did not correlate with subcortical volumes or dMRI measures in the VLBW group. While the deviations in subcortical volumes were substantial, there were few differences in dMRI measures between the two groups, which may reflect the influence of advances in perinatal care on white matter development.

Computerized working memory training has positive long-term effect in very low birthweight preschool children.

AIM: Working memory deficits are frequently found in children born preterm and have been linked to learning disabilities, and cognitive and behavioural problems. Our aim was to evaluate if a computerized working memory training program has long-term positive effects on memory, learning, and behaviour in very-low-birthweight (VLBW) children at age 5 to 6 years. METHOD: This prospective, intervention study included 20 VLBW preschool children in the intervention group and 17 age-matched, non-training VLBW children in the comparison group. The intervention group trained with the Cogmed JM working memory training program daily for 5 weeks (25 training sessions). Extensive neuropsychological assessment and parental questionnaires were performed 4 weeks after intervention and at follow-up 7 months later. For most of the statistical analyses, general linear models were applied. RESULTS: At follow-up, higher scores and increased or equal performance gain were found in the intervention group than the comparison group on memory for faces (p=0.012), narrative memory (p=0.002), and spatial span (p=0.003). No group differences in performance gain were found for attention and behaviour. INTERPRETATION: Computerized working memory training seems to have positive and persisting effects on working memory, and visual and verbal learning, at 7-month follow-up in VLBW preschool children. We speculate that such training is beneficial by improving the ability to learn from the teaching at school and for further cognitive development.

Adaptive behavior in 10-11 year old children born preterm with a very low birth weight (VLBW).

AIMS: The aims were to compare adaptive behavior in 10-11 year old VLBW children with and without cerebral palsy (CP) to term-born children, and examine its relationship with neonatal factors and infant motor repertoire in VLBW children without CP. METHODS: Twenty-eight VLBW children without CP, 10 VLBW children with CP and 31 term-born control children were examined at 10-11 years using the parent-reported Vineland Adaptive Behavior Scales-II. The Adaptive Behavior Composite Score, based on communication, daily living skills and socialization, was adjusted for sex, socioeconomic status (SES), cognitive (WISC-III) and motor function (MABC-2). Associations with neonatal variables and infant motor repertoire were also examined. RESULTS: Adaptive Behavior Composite scores were significantly lower in the two VLBW groups (with CP: 72.5 ± 15.9; without CP: 92.2 ± 12.3) than in the control group (105.7 ± 17.5). The latter difference was still significant after adjustment for sex, SES, WISC-III and MABC-2. Among VLBW children without CP, an abnormal infant motor repertoire at 14 weeks post-term age was significantly associated with a lower Adaptive Behavior Composite score at 10-11 years of age (r(2) = 0.20, p = 0.03). CONCLUSION: VLBW children have challenges regarding adaptive behavior. Specific attention may be needed to reveal such problems in VLBW children without major disabilities like CP, as these children had impaired adaptive function that could not be explained by their SES, cognitive or motor functions.

Follow-up at age 10 years in ELBW children - functional outcome, brain morphology and results from motor assessments in infancy.

BACKGROUND: Extremely-low-birth-weight (ELBW) children without severe brain injury or CP are at high risk of developing deficits within cognition, attention, behavior and motor function. Assessing the quality of an infant's spontaneous motor-repertoire included in Prechtl's General-Movement-Assessment (GMA) has been shown to relate to later motor and cognitive functioning in preterm children without CP. AIMS: To investigate functional outcome and cerebral MRI morphometry at 10 years in ELBW children without CP compared to healthy controls and to examine any relationship with the quality of infant-motor-repertoire included in the GMA. STUDY DESIGN: A cohort-study-design. SUBJECTS: 31 ELBW children (mean birth-weight: 773 g, SD 146, mean gestational age 26.1 weeks, SD 1.8) and 33 term-born, age-matched controls. OUTCOME MEASURES: GMA was performed in ELBW children at 3 months corrected age. At 10 years the children underwent comprehensive motor, cognitive, behavioral assessments and cerebral MRI. RESULTS: The non-CP ELBW children had similar full-IQ but poorer working memory, poorer motor skills, and more attentional and behavioral problems compared to controls. On cerebral MRI reduced volumes of globus pallidus, cerebellar white matter and posterior corpus callosum were found. Cortical surface-area was reduced in temporal, parietal and anterior-medial-frontal areas. Poorer test-results and reduced brain volumes were mainly found in ELBW children with fidgety movements combined with abnormal motor-repertoire in infancy. CONCLUSION: Non-CP ELBW children have poorer functional outcomes, reduced brain volumes and cortical surface-area compared with term-born controls at 10 years. ELBW children with abnormal infant motor-repertoire seem to be at increased risk of later functional deficits and brain pathology.

Assessment of motor behaviour in high-risk-infants at 3 months predicts motor and cognitive outcomes in 10 years old children.

BACKGROUND: The general movement assessment has mainly been used to identify children with cerebral palsy (CP). A detailed assessment of quality of infant motor repertoire using parts of the "Assessment of Motor Repertoire - 3 to 5 Months" which is based on Prechtl's general movement assessment can possibly identify later motor and cognitive problems in children without CP. AIMS: This study aims to determine whether analysis of quality of infant motor repertoire has predictive value for motor and cognitive outcomes at age 10 in children at risk for later neurological impairment. STUDY DESIGN: A longitudinal study design was used. SUBJECTS: Video-recordings of 40 "neurologically high-risk" infants at 14 weeks post-term age were analysed with respect to motor repertoire. OUTCOME MEASURES: Fidgety movements were classified as present or absent. Quality of concurrent motor repertoire was classified as normal if smooth and fluent and abnormal if jerky, monotonous or stiff. Poor motor outcome was defined as a score ≤ 5th centile on the Movement-Assessment-Battery-2, while poor cognitive outcome as total IQ <85 on Wechsler Intelligence Scale-III. RESULTS: Among the high-risk children with presence of fidgety movements, poor motor and/or cognitive outcome at 10 years was identified by abnormal concurrent motor repertoire at 14 weeks post-term age in 86% (95% CI: 0.60-0.96) of the children. On the other hand, 71% (95% CI: 0.47-0.87) of those with normal motor and cognitive outcomes were identified by presence of fidgety movements and normal motor repertoire. CONCLUSIONS: Assessment of quality of infant motor repertoire may be a valuable early clinical marker for later impaired motor and cognitive outcomes in high-risk children who do not develop CP.

Working memory training improves cognitive function in VLBW preschoolers.

BACKGROUND AND OBJECTIVE: Preterm born children perform poorer than term peers on tests of attention and executive functions including working memory tests. Our aim was to evaluate if preterm born preschoolers with very low birth weight (VLBW) would benefit from a computerized working memory training program and if the training would have a generalizing effect on memory, learning, attention, behavior, and anxiety. METHODS: A prospective intervention study with a stepped wedge design where 20 VLBW preschoolers aged 5 to 6 years participated. The children trained with the Cogmed JM program for 10 to 15 minutes a day, 5 days a week over a 5-week period. Extensive neuropsychological assessment and parental questionnaires regarding behavior and anxiety were performed before and 4 weeks after intervention. RESULTS: The children improved significantly on trained (mean Start Index 42.1 [SD 6.3]), mean Max Index 60.6 [SD 5.7]), and nontrained working memory tasks (Spatial Span backward; 2.3 [before] to 3.6 [after training] [confidence interval {CI} -2.2 to -0.4] and Spatial Span total score; 6.4-8.3 [CI -3.7 to -0.1]). A generalization effect was found on auditory attention (49.6-58.2 [CI -15.5 to -1.6]), phonological awareness (9.3-12.6 [CI -5.2 to -1.4]), visual (memory for faces 20.0-24.9 [CI -7.4 to -2.5]), as well as verbal memory (narrative memory; 12.9-17.5 [CI -7.1 to -2.0], and sentence repetition 15.7-17.7 [CI -3.3 to -0.7]). CONCLUSION: This study shows that VLBW preschoolers benefit from a computerized working memory training program. We speculate that such training before starting school may prevent or reduce cognitive problems that impact educational achievement.