Long-term motor development after hypothermia-treated hypoxic-ischaemic encephalopathy.

AIMS: To describe longitudinal motor development in children treated with therapeutic- hypothermia (TH) due to neonatal hypoxic-ischaemic encephalopathy (HIE) and to explore motor functioning in early adolescence. MATERIAL AND METHODS: Children treated with TH due to HIE during 2007-2009, in Stockholm, participated in a prospective follow-up study. Motor development was assessed on four occasions, reported as percentiles and at mean ages. Alberta Infant Motor Scale was used at 0.35 years of age, Bayley Scales of Infant and Toddler Development-III at 2.1 years and Movement Assessment Battery for Children (MABC-2) at 7.3 and 11.1 years of age. MABC-2 Checklist was completed by parents at 7.3 and 11.1 years of age. General cognition was assessed using Wechsler Intelligence Scales for Children Fifth Edition (WISC-V). RESULTS: Thirty-one percent (14/45) of the children had a motor score ≤ 15th percentile, indicating risk of motor difficulties at 11.1 years of age, and simultaneously the scores from parents of 52% (23/44), indicating risk of motor difficulties in the everyday context. These children had significantly lower motor percentile at 2.1 years of age, but within the normal range. Longitudinal motor development displayed a weak association with WISC-V Full Scale IQ (rs0.38, p = 0.013). CONCLUSION: Among survivors of hypothermia-treated HIE free of moderate/severe cerebral palsy, a third had MABC-2 scores indicating risk of motor difficulties at 11.1 years of age. As motor difficulties became more apparent over time, we suggest that children treated with TH due to neonatal HIE should be followed into at least middle school age.

Long-term neurodevelopmental outcome in children born after vacuum-assisted delivery compared with second-stage caesarean delivery and spontaneous vaginal delivery: a cohort study.

OBJECTIVE: To evaluate long-term neurodevelopment in children born after low-or mid-station vacuum-assisted delivery (VAD) compared with children delivered by second-stage caesarean delivery (SSCD) or spontaneous vaginal delivery (SVD). DESIGN: Cross-sectional cohort study. SETTING: Two delivery wards, Karolinska University Hospital, Sweden. PATIENTS: 253 children born by low-station or mid-station VAD, 247 children born after an SVD, and 86 children born via an SSCD accepted to participate. INTERVENTIONS: The Five-to-Fifteen questionnaire was used as a validated screening method for neurodevelopmental difficulties, assessed by parents. MAIN OUTCOMES MEASURES: Results in the Five-to-Fifteen questionnaire. In addition, registered neurodevelopmental ICD-10 diagnoses were collected. Regression analyses estimated associations between delivery modes. RESULTS: Children born after VAD exhibited an increased rate of long-term neurodevelopmental difficulties in motor skills (OR 2.2, 95% CI 1.3 to 3.8) and perception (OR 1.7, 95% CI 1.002 to 2.9) compared with SVD. Similar findings were seen in the group delivered with an SSCD compared with SVD (motor skills: OR 3.3, 95% CI 1.8 to 6.4 and perception: OR 2.3, 95% CI 1.2 to 4.4). The increased odds for motor skills difficulties after VAD and SSCD remained after adjusting for proposed confounding variables. There were significantly more children in the VAD group with registered neurodevelopmental ICD-10 diagnoses such as attention deficit/hyperactivity disorders. CONCLUSIONS: The differences in long-term neurodevelopmental difficulties in children delivered with a VAD or SSCD compared with SVD in this study indicate the need for increased knowledge in the field to optimise the management of second stage of labour.

Outcome at early school age and adolescence after hypothermia-treated hypoxic-ischaemic encephalopathy: an observational, population-based study.

OBJECTIVE: We aimed to describe long-term outcomes following hypoxic-ischaemic encephalopathy (HIE) treated with therapeutic hypothermia (TH). DESIGN: Prospective, population-based observational study. SETTING: Tertiary level neonatal intensive care units and neonatal outpatient clinic, Karolinska University Hospital, Stockholm, Sweden. PATIENTS: Sixty-six infants treated with TH due to HIE between 2007 and 2009. INTERVENTIONS: At 6-8 years and 10-12 years of age, children were assessed using a standardised neurological examination, the Movement Assessment Battery for Children, Second Edition (MABC-2) and the Wechsler Intelligence Scales for Children IV/V. Parents completed the Five-to-Fifteen (FTF) questionnaire. MAIN OUTCOME MEASURES: Adverse outcome among survivors was defined as cerebral palsy (CP), epilepsy, hearing or visual impairment, full-scale IQ (FSIQ) below 85, attention deficit disorder with/without hyperactivity, autism spectrum disorder or developmental coordination disorder. RESULTS: Mortality was 12%. Seventeen per cent of survivors developed CP. Mean FSIQ was normal in children without major neuromotor impairment. Assessment in early adolescence revealed emerging deficits in 26% of children with a previously favourable outcome. The proportion of children exhibiting executive difficulties increased from 7% to 19%. This was reflected also by a significantly increased proportion of children with an FTF score >90th percentile compared with norms in early adolescence. The proportion of children with an MABC-2 score ≤5th percentile was also significantly increased compared with norms. CONCLUSIONS: Survivors without major neuromotor impairment have normal intelligence. The incidence of executive difficulties appears to be increased in this patient population. More subtle difficulties may go undetected at early school-age.

Speech and Language in 5-year-olds with Different Neurological Disabilities and the Association between Early and Later Consonant Production.

The primary aim was to describe speech and language abilities in a clinical group of verbal 5-year-old children diagnosed with neurological disability (ND) in infancy, and the secondary aim was to trace precursors to consonant production at age 5 years (T2) in data from 12 to 22 months (T1). The participants (n = 11, with Down syndrome (DS), cerebral palsy, and chromosomal deletion syndromes) were tested with a battery of speech and language tests. Consonant production at T2 was compared to data on consonant use at T1. At T2, two participants had age appropriate speech and language and another three had age-appropriate speech, but low results on language tests. The remaining six participants had severe speech and language difficulties. Participants with DS had significantly lower results on consonant production measures. An association between consonant production at T1 and T2 for participants with DS indicates that number of different true consonants might be a predictive measure when evaluating young children with DS.

Impaired balance and neurodevelopmental disabilities among children with congenital cytomegalovirus infection.

AIM: Although cytomegalovirus (CMV) is the most common congenital infection, existing research has not provided us with a full picture of how this can affect children in the future. The aim of this case-control study was to evaluate disabilities in a well-defined group of children with congenital cytomegalovirus (CMV) infection, who had been fitted with cochlear implants because of severe hearing impairment. METHODS: A multidisciplinary team assessed 26 children with congenital CMV infection for balance difficulties, neurodevelopmental disabilities and language and visual impairment. We also included a control group of 13 children with severe hearing impairment due to connexin 26 mutations. RESULTS: The majority of the children with congenital CMV infection (88%) displayed balance disturbances, including walking at a later age, but there were no cases in the control group. The CMV group also displayed frequent neurodevelopmental disabilities and feeding difficulties. CONCLUSION: Congenital CMV infection affects the general development of the brain and gives rise to a complex pattern of difficulties. Identifying comorbid conditions is very important, as children with associated difficulties and disabilities need more support than children with just hearing impairment. Congenital CMV infection needs to be considered in children with hearing impairment and/or balance disturbance and/or neurodevelopmental disabilities.

One-year follow-up of tick-borne central nervous system infections in childhood.

BACKGROUND: Neurologic sequelae, including cognitive deficits, after childhood tick-borne encephalitis (TBE) and neuroborreliosis (NB) are not well-characterized. These infections are among the most common affecting the central nervous system in children and can be difficult to diagnose due to vague symptomatology. The aim of this study was to investigate long-term (>1 year) consequences of pediatric TBE and NB as well as the value of markers for brain damage and genetic susceptibility. METHODS: From a previous prospective study, children diagnosed with TBE (n = 8) and NB (n = 12) as well as pediatric controls (n = 15) were followed up by clinical examination, semistructured interview and screening for cognitive dysfunction by the Five-to-Fifteen Questionnaire. The follow-up also included detection of serum autoantibodies against the neural proteins; glial fibrillary acidic protein and myelin basic protein, as well as genotyping of a 32 basepair deletion in the chemokine receptor type 5 gene. RESULTS: Children diagnosed with TBE displayed significantly more long-term subjective complaints (ie, fatigue, headache and irritability) compared with the NB and control groups. Significantly higher frequency of disabilities was also detected by the Five-to-Fifteen Questionnaire in the TBE group. Both TBE and NB cause consequences (eg, prolonged convalescence, worries and financial loss) for the families. Markers for genetic susceptibility and brain damage had no prognostic values in this cohort. CONCLUSIONS: Pediatric TBE results in long-lasting residual symptoms and neurologic deficits affecting daily life. Vigilance for TBE-related morbidity among pediatricians and long-term clinical follow-up with assessment of cognitive dysfunctions and appropriate interventions seems reasonable for these children.

Moderate neonatal encephalopathy: pre- and perinatal risk factors and long-term outcome.

BACKGROUND: The aim was to describe pre- and perinatal data and long-term neurodevelopmental outcome (15-19 years) in children born at term with Apgar score <7 at 5 min and moderate neonatal encephalopathy. METHODS: The study is based on a population-based birth-cohort of children born in Sweden in 1985. Maternal, delivery, neonatal, and neuropaediatric data were compiled. Neurodevelopmental status was classified according to the presence of 1. cerebral palsy or other major impairments, 2. exclusively cognitive impairments, and 3. no impairments. RESULTS: The majority of the children (81%) had cognitive dysfunctions, with or without other impairments, such as cerebral palsy. The rates of post-term birth (19% versus 8%) and breech presentation (12% versus 3%) were significantly higher than in the general Swedish population. Pre- and perinatal data did not differ notably between the three outcome groups. Questionable or suboptimal obstetric care was common (55%). CONCLUSIONS: The study shows that children born at term with moderate neonatal encephalopathy have a high rate of cognitive dysfunctions with or without cerebral palsy at long-term follow-up. Our pre- and perinatal data did not correlate with outcome.

Teenage outcome after being born at term with moderate neonatal encephalopathy.

The aim of this study was to assess cognitive functions and behavior problems in teenagers who survived moderate neonatal encephalopathy and did not develop cerebral palsy. The study population comprised all 97,468 individuals born in Sweden in 1985. Of these, 684 (0.7%) were born at term and had an Apgar score of <7 at 5 minutes. The obstetric and neonatal records were scrutinized and the individuals were classified according to degree of neonatal encephalopathy. Teenagers with moderate neonatal encephalopathy without cerebral palsy and other major neuro-impairments were subjected to a clinical assessment including interviews, neuropsychological tests, and assessments of data from records. Age at examination was 15-19 years. Fifty-six individuals who had moderate neonatal encephalopathy were identified. Thirteen (23%) had parents who declined participation in the study. Of the remaining 43 subjects, 15 (30%) had a diagnosis of cerebral palsy or other major neuro-impairments and 28 had no such impairments. The latter group was examined, 20 of whom (71%) had definite cognitive dysfunctions. Five (18%) had hearing impairments. Only eight teenagers were without impairments. Of those who did not have cerebral palsy, the majority had cognitive/executive problems that interfered with their daily life situation. Clinical follow-up, including assessments of cognitive functions before school start, should be considered for all individuals in this high-risk group.

Diffusion tensor imaging on teenagers, born at term with moderate hypoxic-ischemic encephalopathy.

Hypoxic-ischemic encephalopathy (HIE) is graded with three levels of severity-mild, moderate and severe. The outcome of individuals with mild and severe grades can be reliably predicted from this scheme. Individuals with moderate degree are divided in outcome between those who suffer major neurologic problems (e.g., cerebral palsy) and those who are assumed to recover from the incident. It is however not clear if the recovery is complete and unquestionable. A group of adolescents who had been born at term, diagnosed with moderate HIE but had not developed cerebral palsy, were investigated with diffusion tensor imaging. Fractional anisotropy maps were used as a basis of comparison to a group of controls of the same age and gender distribution. In several white matter areas fractional anisotrophy was lower in the group of individuals with a history of moderate HIE. These areas include the internal capsules (bilaterally in the posterior limb and on the right in the anterior limb), the posterior and anterior corpus callosum as well as frontal inferior white matter areas. These results indicate that even in the absence of such major neurologic impairments as cerebral palsy, moderate HIE causes long term white matter disturbances which are not repaired by adolescence.

Developmental data in preschool children born after prolonged pregnancy.

AIM: To evaluate children born post-term (gestational age>or=42 weeks) with respect to developmental data obtained at the ages of 4 and 5.5 y. METHODS: The study population included all children (n=354) born in 1991 at Huddinge University Hospital with a gestational age of >or=42 wk. The births were identified and perinatal data were collected through the Swedish National Birth Registry. Developmental assessments from the child health centres were analysed. Children born at term, but before a gestational age of 42 wk, served as controls. Logistic regression analysis was used to analyse the data. RESULTS: Children born post-term had more developmental deviations than the controls (estimated odds ratio 2.20; 95% CI: 1.29-3.85). Boys had more deviations than girls (estimated odds ratio 1.92; 95% CI: 1.11-3.45). CONCLUSION: Our results indicate that there might be an association between post-term birth and developmental deviations.