Parent implementation of a treatment for late talkers based on cross-situational statistical learning principles: Treatment fidelity and acceptability.

PURPOSE: Early intervention based on principles of cross-situational statistical learning (CSSL) for late-talking children has shown promise. This study explored whether parents could be trained to deliver this intervention protocol with fidelity and if they found the intervention to be acceptable. METHOD: Mothers of four English-speaking children aged 18-30 months who scored <10th centile for expressive vocabulary were recruited to an 8-week group training program. Parents were taught principles of CSSL and asked to perform 16 home treatment sessions (30 minutes each) in total, providing auditory bombardment of target words in full sentences at high dose number and syntactic variability, using a range of physical exemplars. Home diaries and two videotaped sessions measured treatment fidelity. Pre- and post-treatment questionnaires measured acceptability. RESULT: One parent discontinued the study after the second group training session. Three parents completed 15/16 group training sessions and reported completing 87% of home sessions. Two parents demonstrated implementing the intervention as per the target dose number by the first fidelity session (Weeks 2/3), and the third parent was very close to meeting target dose number by the second fidelity session (Weeks 7/8). CONCLUSION: Parents can be trained to deliver an intervention based on cross-situational statistical learning principles.

Replication of a single-case design cross-situational statistically based word learning treatment for late talking children.

PURPOSE: Late talking children are at risk of ongoing language impairment. This intervention study replicated and extended research based on cross-situational statistical learning principles. METHOD: Three late talking children (age 24-32 months) were enrolled into the concurrent multiple baseline single-case experimental intervention study. The intervention consisted of 16 sessions over eight/nine weeks, including 10-11 pairs of target and control words (three per session). Children heard the target words a minimum of 64 times per session, in sentences with high linguistic variability in varied play activities. RESULT: All children increased production of target words and expressive vocabulary, with statistically significant differences between word acquisition in baseline and intervention phases. One of the three children learnt statistically significantly more target words than control words. CONCLUSION: The results replicated the findings of previous research for some but not all of the participants, providing individual evidence that this approach has promise as a therapy technique for late talking children.

Can Dynamic Assessment Identify Language Disorder in Multilingual Children? Clinical Applications From a Systematic Review.

PURPOSE: Multilingual children are disproportionately represented on speech pathology caseloads, in part due to the limited ability of traditional language assessments to accurately capture multilingual children's language abilities. This systematic review evaluates the evidence for identification of language disorder in multilingual children using dynamic assessment and considers clinical applications of the evidence. METHOD: A systematic search of the Cumulative Index to Nursing and Allied Health Literature, Education Resources Information Centre, Education Source, Google Scholar, Linguistics, Medline, and PsycINFO databases produced 10 articles that met the inclusion criteria: between-groups comparison studies that used dynamic assessment to identify language disorder in children under 12 years old that spoke a different language at home to the majority society language. Articles were critically appraised using the Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) protocol. RESULTS: Nine of the 10 studies reported that their dynamic assessment identified language disorder in multilingual children. However, small sample sizes, limited language pairs, variability in the reference standard, and design deficiencies resulted in poor ratings for all studies on QUADAS-2. CONCLUSIONS: The studies in this review reflected an emergent area of research. Preliminary guidelines for clinical application indicate that dynamic assessment may be a suitable and time-efficient complementary method of diagnosis of language disorder in multilingual children. Further recommendations about age of use, language of instruction, and relevant scores are included.

Do infants of breast-feeding mothers benefit from additional long-chain PUFA from fish oil? A 6-year follow-up.

Fish-oil supplements are marketed as enhancing intelligence and cognitive performance. However, empirical data concerning the utility of these products in healthy term infants are mixed, particularly with respect to lasting effects into childhood. We evaluated whether fish-oil supplementation during infancy leads to better neurocognitive/behavioural development at 6 years. We conducted a double-blind randomised controlled trial of supplementation with n-3 long-chain PUFA in 420 healthy term infants. Infants received either fish oil (containing at least 250 mg DHA and at least 60 mg EPA) or placebo (olive oil) daily from birth to 6 months of age. Neurodevelopmental follow-up was conducted at a mean age of 6 years (sd 7 months), whereby 335 children were assessed for language, executive functioning, global intelligence quotient and behaviour. No significant differences were observed between the groups for the main neurocognitive outcomes. However in parent-report questionnaire, fish-oil supplementation was associated with negative externalising (P = 0·035, d = 0·24) and oppositional/defiant behaviour (P = 0·006, d = 0·31), particularly in boys (P = 0·01, d = 0·45; P = 0·004, d = 0·40). Our results provide evidence that fish-oil supplementation to predominantly breast-fed infants confers no significant cognitive or behavioural benefit to children at 6 years.

FADS1 and FADS2 Polymorphisms Modulate Fatty Acid Metabolism and Dietary Impact on Health.

Variants in the FADS gene cluster modify the activity of polyunsaturated fatty acid (PUFA) desaturation and the lipid composition in human blood and tissue. FADS variants have been associated with plasma lipid concentrations, risk of cardiovascular diseases, overweight, eczema, pregnancy outcomes, and cognitive function. Studies on variations in the FADS genecluster provided some of the first examples for marked gene-diet interactions in modulating complex phenotypes, such as eczema, asthma, and cognition. Genotype distribution differs markedly among ethnicities, apparently reflecting an evolutionary advantage of genotypes enabling active long-chain PUFA synthesis when the introduction of agriculture provided diets rich in linoleic acid but with little arachidonic and eicosapentaenoic acids. Discovering differential effects of PUFA supply that depend on variation of FADS genotypes could open new opportunities for developing precision nutrition strategies based either on an individual's genotype or on genotype distributions in specific populations.

Can polymorphisms in the fatty acid desaturase (FADS) gene cluster alter the effects of fish oil supplementation on plasma and erythrocyte fatty acid profiles? An exploratory study.

PURPOSE: The enzymes encoded by fatty acid desaturases (FADS) genes determine the desaturation of long-chain polyunsaturated fatty acids (LCPUFA). We investigated if haplotype and single nucleotide polymorphisms (SNPs) in FADS gene cluster can influence LCPUFA status in infants who received either fish oil or placebo supplementation. METHODS: Children enrolled in the Infant Fish Oil Supplementation Study (IFOS) were randomly allocated to receive either fish oil or placebo from birth to 6 months of age. Blood was collected at 6 months of age for the measurement of fatty acids and for DNA extraction. A total of 276 participant DNA samples underwent genotyping, and 126 erythrocyte and 133 plasma fatty acid measurements were available for analysis. Twenty-two FADS SNPs were selected on the basis of literature and linkage disequilibrium patterns identified from the HapMap data. Haplotype construction was completed using PHASE. RESULTS: For participants allocated to the fish oil group who had two copies of the FADS1 haplotype consisting of SNP minor alleles, DHA levels were significantly higher compared to other haplotypes. This finding was not observed for the placebo group. Furthermore, for members of the fish oil group only, the minor homozygous carriers of all the FADS1 SNPs investigated had significantly higher DHA than other genotypes (rs174545, rs174546, rs174548, rs174553, rs174556, rs174537, rs174448, and rs174455). CONCLUSIONS: Overall results of this preliminary study suggest that supplementation with fish oil may only significantly increase DHA in minor allele carriers of FADS1 SNPs. Further research is required to confirm this novel finding.

A Randomized, Controlled Trial of Behavioral Voice Therapy for Dysphonia Related to Prematurity of Birth.

OBJECTIVES: Dysphonia is a potential complication of prematurity. Preterm children may sustain iatrogenic laryngeal damage from medical intervention in the neonatal period, and further, adopt compensatory, maladaptive voicing behaviors. This pilot study aimed to evaluate the effects of a voice therapy protocol on voice quality in school-aged, very preterm (VP) children. METHODS: Twenty-seven VP children with dysphonia were randomized to an immediate intervention group (n = 7) or a delayed-intervention, waiting list control group (n = 14). Following analysis of these data, a secondary analysis was conducted on the pooled intervention data (n = 21). Six participants did not complete the trial. RESULTS: Change to voice quality was measured via pre- and posttreatment assessments using the Consensus Auditory Perceptual Evaluation of Voice. The intervention group did not demonstrate statistically significant improvements in voice quality, whereas this was observed in the control group (P = 0.026). However, when intervention data were pooled including both the immediate and delayed groups following intervention, dysphonia severity was significantly lower (P = 0.026) in the treatment group. CONCLUSIONS: Dysphonia in most VP children in this cohort was persistent. These pilot data indicate that some participants experienced acceptable voice outcomes on spontaneous recovery, whereas others demonstrated a response to behavioral intervention. Further research is needed to identify the facilitators of and barriers to intervention success, and to predict those who may experience spontaneous recovery.

Docosahexaenoic Acid and Neurodevelopmental Outcomes of Term Infants.

Docosahexaenoic acid (DHA), a long-chain polyunsaturated fatty acid, is essential for normal brain development. DHA is found predominantly in seafood, fish oil, breastmilk and supplemented formula. DHA intake in Western countries is often below recommendations. Observational studies have demonstrated an association between DHA intake in pregnancy and neurodevelopment of offspring but cannot fully adjust for confounding factors that influence child development. Randomised clinical trials of DHA supplementation during pregnancy and/or lactation, and of term infants, have not shown a consistent benefit nor harm on neurodevelopment of healthy children born at term. The evidence does not support DHA supplementation of healthy pregnant and lactating women, nor healthy infants.

Voice problems in school-aged children following very preterm birth.

BACKGROUND AND OBJECTIVE: Very preterm children may be at risk of voice abnormalities (dysphonia). Risk factors previously identified in extremely preterm children include female gender, multiple intubations, complicated intubation and very low birth weight. This study sought to identify the prevalence of dysphonia in very preterm children, at school age. METHODS: Children born between 23 and 32 weeks' gestation were included in this prospective observational study. Participants were randomly selected from a sample stratified by gestational age and number of intubations, and were aged between 5 and 12 years at the time of assessment. Clinical voice assessments were conducted by a speech pathologist, and a diagnosis of dysphonia was made based on the presence and severity of disturbance to the voice. Retrospective chart review identified medical and demographic characteristics. RESULTS: 178 participants were assessed. The prevalence of dysphonia in this cohort was 61%. 31% presenting with significant dysphonia, that is, voice disturbance of greater than mild in severity. Female gender (p=0.009), gestational age (p=0.031) and duration of intubation (p=0.021) were significantly associated with dysphonia although some preterm children with dysphonia were never intubated. CONCLUSIONS: Significant voice abnormalities were observed in children born at up to 32 weeks' gestation, with intubation a major contributing factor. TRIAL REGISTRATION NUMBER: ACTRN12613001015730.

Dysphonia in extremely preterm children: A longitudinal observation.

INTRODUCTION: Dysphonia is a potential long-term complication of preterm birth. Childhood voice disorders caused by vocal hyperfunction resolve with pubertal changes to the vocal mechanism in many cases. In extremely preterm children, whose voice quality is affected by supraglottic hyperfunction adapted secondary to underlying structural laryngeal pathology sustained during neonatal intubation, the prognosis is unknown. METHODS: A pilot study was conducted to assess the incidence and severity of dysphonia in children born at < 25 weeks' gestation. Ten individuals, aged between 9.67 and 17.08 years, presented for repeat assessment in a replication and extension of the original study. The mean period between assessments was 2.85 (SD 0.38) years. The primary outcome measure was the severity score on the Consensus Auditory-Perceptual Evaluation of Voice (CAPE-V), with the Acoustic Voice Quality Index score as the secondary outcome measure. Scores on the Pediatric Voice Handicap Index were also compared. RESULTS: Perceptual dysphonia severity scores were significantly lower on repeat assessment, but no differences were observed in objective or quality of life scores. Individual variation was observed: the difference in CAPE-V scores ranged from -36 to + 1. No participant presented with normal voice quality on repeat assessment. DISCUSSION: Analysis of group data masked individual variability in this series. Mechanisms underlying such individual variation are currently unknown. These data suggest that dysphonia is persistent in extremely preterm children. CONCLUSION: Further investigation is warranted to elucidate the progression of voice disorders in extremely preterm children, to inform prognostic predictors and treatment decisions.

Maternal fish oil supplementation in pregnancy: a 12 year follow-up of a randomised controlled trial.

A number of trials have been undertaken to assess whether the intake of omega-3 long-chain polyunsaturated fatty acids (n-3 LCPUFA) during pregnancy can influence the neurological development of the offspring, yet no consensus from these trials has been reached. We aimed to investigate the long-term effects (12 years) of fish oil supplementation in pregnancy on neurodevelopment, including cognition, language and fine motor skills. In a follow up of a previously published randomised controlled trial of 98 pregnant women, their children were assessed at 12 years of age using a battery of neurodevelopmental assessments. Fifty participants were assessed at 12 years, with 25 participant's mothers receiving fish oil supplementation, and 25 receiving control capsules. There were no significant differences for any of the assessment measures completed. Our data indicate that fish oil supplementation during pregnancy does not influence the cognition, language or fine motor skills of children in late primary school (12 years of age).

Laryngeal pathology at school age following very preterm birth.

INTRODUCTION: Intubation injury resulting in laryngeal pathology is recognised as a possible complication of preterm birth, yet few published studies have examined such pathology and its relation to voice outcomes. This study reports on the results of prospective laryngeal function examinations of a cohort of very preterm children, all of whom presented with significant dysphonia at school age. MATERIALS AND METHODS: The laryngeal pathology of 20 very preterm children, born between 23 and 29 weeks gestation, was examined under halogen and stroboscopic conditions. Laryngeal structure and function were assessed using a rigid laryngoscope or a flexible nasendoscope. The approach was selected based on the age and/or likely compliance of the child. RESULTS: Nineteen children were found to have structural laryngeal pathology. Fourteen children presented with a chink to the posterior glottis and all demonstrated at least a mild degree of supraglottic hyperfunction. Other common findings were arytenoid prolapse and vocal fold immobility. More isolated findings included posterior scar band, vocal fold atrophy, arytenoid oedema and growth on the vocal folds. One child who presented with structural laryngeal pathology was never intubated. DISCUSSION: Supraglottic hyperfunction was common to all participants, regardless of the nature and extent of underlying structural laryngeal pathology. Posterior glottic chink was the most common pattern of incomplete vocal fold closure. These data support the hypothesis that very preterm children adopt supraglottic tightening to compensate for underlying laryngeal pathology. The mechanism underlying laryngeal damage in the child who was not intubated is unclear. CONCLUSIONS: Voice quality of very preterm children is affected by both laryngeal structure and function. A trial of behavioural voice treatment is recommended to evaluate any therapeutic response in this population.

Dysphonia in very preterm children: a review of the evidence.

INTRODUCTION: Intubation is a known risk factor for dysphonia yet is essential in the perinatal care of many very preterm infants. Children born preterm, who are frequently resuscitated with endotracheal intubation, may be at risk of dysphonia at school age and beyond. OBJECTIVES: To identify and describe the evidence pertaining to long-term voice outcomes and risk factors for developing dysphonia in preterm children. RESULTS: In addition to case studies and series, three larger-scale studies have reported on dysphonia and voice outcomes in preterm children. Studies reporting treatment outcomes were not available. Factors associated with poor voice outcomes included female gender, birth weight <1,000 g, birth at <27 weeks' gestation, surgical closure of patent ductus arteriosus, emergency versus elective intubations and multiple intubations. Adverse voice outcomes were associated with laryngeal pathology and compensatory supraglottic compression. CONCLUSIONS: Dysphonia is a newly reported, long-term complication of preterm birth, yet the number of relevant studies remains limited. Further research is required to confirm the risk factors for developing dysphonia, which will inform future voice treatment studies.

Dysphonia in preterm children: assessing incidence and response to treatment.

BACKGROUND: Mild dysphonia in childhood is surprisingly common, yet moderate to severe dysphonia is rare. The latter has been associated with complex medical conditions and congenital abnormalities. Intubation injury has also been documented as a cause of childhood dysphonia. Children born very preterm may be intubated as part of the intensive care administered in the perinatal and neonatal periods, yet there are few studies investigating dysphonia in this population. This study will be the first to: use an objective acoustic voice assessment in a paediatric study, document the incidence of dysphonia in very preterm children at school age, and conduct a controlled trial of behavioural voice therapy in this population. DESIGN: This study will consist of three phases: assessment of voice quality and its impact on quality of life in up to 200 children born at less than 32 weeks' gestation: assessment of the nature and extent of laryngeal pathology in children with moderate to severe dysphonia; and a non-blinded, randomised controlled trial of behavioural voice therapy in children with moderate to severe dysphonia. DISCUSSION: This study will be the first to use clinical assessment to examine the voice quality of very preterm children, and to use fibre optic endoscopic evaluation of laryngeal function to determine the nature and extent of any laryngeal pathology in such children. Those participants with significant voice difficulties will be randomised to receive treatment immediately or after the eight week assessment. TRIAL REGISTRATION: This study is registered on the Australian New Zealand Clinical Trials Registry (ACTRN12613001015730/ACTRN12613001012763).

Does docosahexaenoic acid supplementation in term infants enhance neurocognitive functioning in infancy?

The proposal that dietary docosahexaenoic acid (DHA) enhances neurocognitive functioning in term infants is controversial. Theoretical evidence, laboratory research and human epidemiological studies have convincingly demonstrated that DHA deficiency can negatively impact neurocognitive development. However, the results from randomized controlled trials (RCTs) of DHA supplementation in human term-born infants have been inconsistent. This article will (i) discuss the role of DHA in the human diet, (ii) explore the physiological mechanisms by which DHA plausibly influences neurocognitive capacity, and (iii) seek to characterize the optimal intake of DHA during infancy for neurocognitive functioning, based on existing research that has been undertaken in developed countries (specifically, within Australia). The major observational studies and RCTs that have examined dietary DHA in human infants and animals are presented, and we consider suggestions that DHA requirements vary across individuals according to genetic profile. It is important that the current evidence concerning DHA supplementation is carefully evaluated so that appropriate recommendations can be made and future directions of research can be strategically planned.

Autism spectrum disorder in children born preterm-role of exposure to perinatal inflammation.

Autism Spectrum Disorder (ASD) is the collective term for neurodevelopmental disorders characterized by qualitative impairments in social interaction, communication, and a restricted range of activities and interests. Many countries, including Australia, have reported a dramatic increase in the number of diagnoses over the past three decades, with current prevalence of ASD at 1 in every 110 individuals (~1%). The potential role for an immune-mediated mechanism in ASD has been implicated by several studies, and some evidence suggests a potential link between prenatal infection-driven inflammation and subsequent development of ASD. Furthermore, a modest number of contemporary studies have reported a markedly increased prevalence of ASD in children born preterm, who are at highest risk of exposure to perinatal inflammation. However, the mechanisms that underpin the susceptibility to infection-driven inflammation during pregnancy and risk of preterm birth, and how these intersect with the subsequent development of ASD in the offspring, is not understood. This review aims to summarize and discuss the potential mechanisms and evidence for the role of prenatal infection on the central nervous system, and how it may increase the susceptibility for ASD pathogenesis in children born preterm.

Voice abnormalities at school age in children born extremely preterm.

BACKGROUND AND OBJECTIVES: Voice abnormality is a frequent finding in school age children born at <25 weeks' gestation in Western Australia. The objective of this study was to determine the frequency of voice abnormality, voice-related quality of life, and demographic and intubation factors in this population. METHODS: Survivors <25 weeks' gestational age in Western Australia born from 1996 to 2004 were included. Voice assessments (auditory perceptual assessment scale and Pediatric Voice Handicap Index) were carried out by speech pathologists. Intubation history was obtained by retrospective chart review. RESULTS: Of 251 NICU admissions, 154 (61%) survived. Exclusions were based on severe disability (11) or distant residence (13). Of 70 assessed, 67 completed assessments, 4 (6%) were in the normal range and 39 (58%) showed moderate-severe hoarseness. Simultaneous modeling of demographic and intubation characteristics showed an increased odds of moderate-severe voice disorder for children who had more than 5 intubations (odds ratio 6.96, 95% confidence interval 2.07-23.40, P = .002) and for girls relative to boys (odds ratio 3.46, 95% confidence interval 1.12-10.62, P = .030). Tube size and duration of intubation were not significant in the multivariable model. Median scores of parent-reported voice quality of life on the Pediatric Voice Handicap Index were markedly different for preterm (22) and term (3) groups, P < .001. CONCLUSIONS: Voice disorders in this population were much more frequent than expected. Further studies are required to assess voice across a broader range of gestational ages, and to investigate voice-protective strategies in infants requiring multiple episodes of intubation.

Associations between maternal antioxidant intakes in pregnancy and infant allergic outcomes.

Antioxidant intakes in pregnancy may influence fetal immune programming and the risk of allergic disease. We investigated associations between maternal intakes of ß-carotene, vitamin C, vitamin E, copper and zinc, and infant allergic outcomes. Antioxidant intakes of pregnant women (n = 420) assessed prospectively by a food frequency questionnaire, were examined in relation to allergic outcomes at 1 year of age (n = 300). The main relationships with allergic outcomes were seen with dietary vitamin C and copper. Specifically, higher maternal dietary vitamin C intake was associated with a reduced risk of any diagnosed infant allergic disease and wheeze. After adjustment for potential confounders the relationship with wheeze remained statistically significant. There was also an inverse linear relationship between vitamin C and food allergy. Higher dietary copper intake was associated with reduced risk of eczema, wheeze and any allergic disease. The relationship with wheeze and any allergic disease remained statistically significant in multivariate analysis, and there was also an inverse linear relationship between copper and food allergy. However, these relationships were only seen for nutrients present in food. There were no relationships between ß-carotene, vitamin E or zinc and any allergic outcomes. In summary, this study suggests that maternal diet of fresh foods rich in vitamin C is associated with reduced risk of infant wheeze, and that copper intake is associated with reduced risk of several allergic outcomes.

Effects of high-dose fish oil supplementation during early infancy on neurodevelopment and language: a randomised controlled trial.

n-3 Long-chain PUFA (LC-PUFA) intake during infancy is important for neurodevelopment; however, previous studies of n-3 LC-PUFA supplementation have been inconclusive possibly due to an insufficient dose and limited methods of assessment. The present study aimed to evaluate the effects of direct supplementation with high-dose fish oil (FO) on infant neurodevelopmental outcomes and language. In the present randomised, double-blind, placebo-controlled trial, 420 healthy term infants were assigned to receive a DHA-enriched FO supplement (containing at least 250 mg DHA/d and 60 mg EPA/d) or a placebo (olive oil) from birth to 6 months. Assessment occurred at 18 months via the Bayley Scales of Infant and Toddler Development (3rd edition; BSID-III) and the Child Behavior Checklist. Language assessment occurred at 12 and 18 months via the Macarthur-Bates Communicative Development Inventory. The FO group had significantly higher erythrocyte DHA (P = 0·03) and plasma phospholipid DHA (P = 0·01) levels at 6 months of age relative to placebo. In a small subset analysis (about 40% of the total population), children in the FO group had significantly higher percentile ranks of both later developing gestures at 12 and 18 months (P = 0·007; P = 0·002, respectively) and the total number of gestures (P = 0·023; P = 0·006, respectively). There was no significant difference between the groups in the standard or composite scores of the BSID-III. The results suggest that improved postnatal n-3 LC-PUFA intake in the first 6 months of life using high-dose infant FO supplementation was not beneficial to global infant neurodevelopment. However, some indication of benefits to early communicative development was observed.