Temperature probe placement in very preterm infants during delivery room stabilization: an open-label randomized trial.

BACKGROUND: Variation in practice exists for temperature probe positioning during stabilization of very preterm infants (<32 weeks gestation). We explored the influence of temperature probe sites on thermoregulation. METHODS: An open-label, stratified, balanced, parallel, randomized trial was conducted. Inborn infants were randomly assigned temperature probe to the axilla or to the upper back. The primary outcome was normothermia (local range: 36.8-37.3 °C and World Health Organization (WHO) range: 36.5-37.5 °C) at admission to the neonatal intensive care unit. RESULTS: Between 1 November 2018 and 4 July 2022, 178 infants were randomly assigned to one of the two sites (n = 89 each), 175 included in the final analysis. Normothermia (local range) was achieved for 39/87 infants (44.8%) assigned to the upper back compared to 28/88 infants (31.8%) assigned to the axilla [risk difference:13%; 95% CI -1.3-27.3]. Normothermia (WHO range) was achieved for 78/87 infants (89.7%) assigned to the upper back compared to 70/88 infants (79.6%) assigned to the axilla [risk difference:10.1%; 95% CI -0.5-20.7]. No infant recorded temperatures >38 °C or developed skin injury. CONCLUSIONS: In very preterm infants, upper back site was equally effective as the axilla in maintaining normothermia, with no increase in adverse events. CLINICAL TRIAL REGISTRATION: The study was registered with the Australian New Zealand Clinical Trials Registry (ACTRN12620000293965). IMPACT: Substantial variation in practice exists for the site of securing a temperature probe during delivery room stabilization of very preterm infants and the influence of temperature probe site on thermoregulation remains unknown. In this study, upper back site was equally effective as the axilla in maintaining normothermia, with no increase in adverse events. Clinicians could adopt upper back site for maintaining normothermia. This study may contribute data to future international participant data prospective meta analysis of randomized controlled trials worldwide on temperature probe positioning in very preterm infants, increasing translation of research findings to optimize thermoregulation and clinical outcomes.

Systemic postnatal corticosteroid use for the prevention of bronchopulmonary dysplasia and its relationship to early neurodevelopment in extremely preterm infants.

BACKGROUND: Systemic postnatal corticosteroid use in extremely preterm infants poses a risk of adverse neurodevelopmental outcomes. This study explores their use beyond seven days of age with early neurodevelopmental assessments during the fidgety period (9-20 weeks postterm age). METHODS: This retrospective single-center cohort study included inborn extremely preterm infants from 1 January 2014 to 31 December 2018. Outborn infants, those with congenital or genetic abnormalities, and those who received postnatal corticosteroids for nonrespiratory reasons were excluded. The cohort was dichotomized based on the status of corticosteroid receipt. Early neurodevelopmental outcomes were reported using Prechtl's General Movements Assessment. RESULTS: Of the 282 infants, 67 (23.75%) received corticosteroids. Of these, 34 (50.75%) received them for dependency on invasive ventilation (intermittent positive-pressure ventilation), and the remainder received them for dependency on non-invasive ventilation continuous positive airway pressure (CPAP) or bi-level positive airway pressure (BiPAP). Abnormal or absent fidgety movements were observed in 13% of infants (7/54) who received corticosteroids compared to 2% of infants (3/146) who did not. An increased odds for an abnormal general movements assessment from corticosteroid use after adjusting for gestational age [adjusted odds ratio (aOR) = 5.5, 95% confidence interval (CI) = 1.14-26.56] was observed. The motor optimality scores differed between the two groups [corticosteroid group: 25.5 (23-26) versus no-corticosteroid group: 26 (24-28); z = - 2.02]. A motor optimality score < 20 was observed in 14.8% of infants (8/54) in the corticosteroid group compared to 2% of infants (3/146) in the noncorticosteroid group. This difference was significant after adjustment for gestational age (aOR 5.96, 95% CI 1.28-27.74). CONCLUSIONS: Abnormal early neurodevelopment was observed in infants who received systemic postnatal corticosteroids. The relationship between these findings and other factors influencing early neurodevelopment needs further exploration.

Regional oxygenation, perfusion and body and/or head position: Are preterm infants adversely impacted? A systematic review.

This review addresses regional oxygenation and perfusion changes for preterm infants and changes with body position, with or without head rotation. Future directions for improving neurodevelopmental and clinical outcomes are suggested. The MEDLINE, Embase and Scopus databases were searched up to July 2021. Fifteen out of 470 studies met the inclusion criteria. All were prospective, observational studies with a moderate risk of bias. Significant variation was found for the baseline characteristics of the cohort, postnatal ages, and respiratory support status at the time of monitoring. When placed in a non-supine position, preterm infants showed a transient reduction in cardiac output and stroke volume without changes to heart rate or blood pressure. No studies reported on long-term neurodevelopmental outcomes. Overall, side lying or prone position does not appear to adversely affect regional, and specifically cerebral, oxygenation or cerebral perfusion. The effect of head rotation on regional oxygenation and perfusion remains unclear.

Cerebral Oxygenation and Perfusion when Positioning Preterm Infants: Clinical Implications.

OBJECTIVES: To evaluate cerebral tissue oxygenation (cTOI) and cerebral perfusion in preterm infants in supine vs prone positions. STUDY DESIGN: Sixty preterm infants, born before 32 weeks of gestation, were enrolled; 30 had bronchopulmonary dysplasia (BPD, defined as the need for respiratory support and/or supplemental oxygen at 36 weeks of postmenstrual age). Cerebral perfusion, cTOI, and polysomnography were measured in both the supine and prone position with the initial position being randomized. Infants with a major intraventricular hemorrhage or major congenital abnormality were excluded. RESULTS: Cerebral perfusion was unaffected by position or BPD status. In the BPD group, the mean cTOI was higher in the prone position compared with the supine position by a difference of 3.27% (P = .03; 95% CI 6.28-0.25) with no difference seen in the no-BPD group. For the BPD group, the burden of cerebral hypoxemia (cumulative time spent with cTOI <55%) was significantly lower in the prone position (23%) compared with the supine position (29%) (P < .001). In those without BPD, position had no effect on cTOI. CONCLUSIONS: In preterm infants with BPD, the prone position improved cerebral oxygenation and reduced cerebral hypoxemia. These findings may have implications for positioning practices. Further research will establish the impact of position on short- and long-term developmental outcomes.

Sensitivity and specificity of general movements assessment for detecting cerebral palsy in an Australian context: 2-year outcomes.

AIM: We previously reported sensitivity and specificity levels of the general movements assessment (GMA) to detect cerebral palsy (CP) at 1 year within a clinical setting and with the assistance of the New South Wales (NSW) Rater Network. The aim of this study was to determine whether similarly high levels of validity could be maintained in the same group at 2 years. METHODS: A prospective longitudinal cross-sectional study was conducted. GMA was blind-rated from conventional video by two independent certified raters, blinded to medical history. A third rater resolved disagreements. High-risk population screening for CP using the GMA during the fidgety period (12-20 weeks) was carried out in four neonatal intensive care units and one CP service over a 30-month period. Participants were 259 high-risk infants for the initial study. Multidisciplinary follow-up at 2-3 years included Bayley Scales of Infant Development and confirmed diagnosis of CP. Sensitivity and specificity values were calculated with true positives defined as a confirmed diagnosis of CP. RESULTS: At 2-3 years, 184 (71%) completed the follow-up assessment. GMA was normal for 134 (73%, low risk for CP), absent fidgety for 48 (26%, high risk for CP) and abnormal fidgety for 2 (1%, high risk for abnormal neurological disorder). Sensitivity for detecting CP was 97.6% (40/41) and specificity 95.7% (133/139). Sensitivity for detecting any abnormal outcome with absent/abnormal fidgety general movements (GMs) was 57.9% (44/76) and specificity 94.4% (101/107). CONCLUSION: Excellent levels of sensitivity and specificity of the GMA for detecting CP in the clinical setting were maintained at 2 years and were similar to our previously reported findings.

General Movement assessment and neurodevelopmental trajectory in extremely preterm infants with hypothyroxinaemia of prematurity (THOP).

BACKGROUND: Transient hypothyroxinaemia of prematurity (THOP) has been associated with neurodevelopmental deficits with a paucity of literature leading to variable practice. AIM: Evaluation of the relationship between free T4 (fT4) levels at 2 weeks after birth and early markers of neurodevelopmental outcome. STUDY DESIGN: A retrospective study of prospectively collected data from infants born <29 weeks' gestation, admitted to NICU between January 2012 and December 2014. The primary outcomes were the relationship between fT4 levels at 2 weeks, Prechtl General Movement Assessment (GMA) at 36 weeks and 3 months postterm age, and Bayley Scales of Infant Development (BSID-III) at 2 years postterm age. Secondary outcomes were survival free of disability and other neonatal morbidities. RESULTS: Of 122 infants, 101 infants had normal fT4 levels (No-THOP) and 21 had fT4 levels >1SD below the mean (THOP group). There was increased frequency of abnormal GMA in the No-THOP group compared with the THOP group at 36 weeks (abnormal writhing GMs: 43% vs 21%, p = 0.15) and 3 months corrected age (absent fidgety GMs: 7.6% vs 0%, p = 0.36), though not statistically significant. The neurodevelopmental outcome was worse in the No-THOP group compared with the THOP group with significantly lower mean cognitive and motor scores at 2 year of corrected age (90 ±â€¯13.8 vs 100 ±â€¯8.3, p = 0.01 and 91 ±â€¯15.2 vs 100 ±â€¯13.2, p = 0.04 respectively). CONCLUSIONS: This is the first report describing General Movements (GMs) in preterm infants with THOP. We found worse neurodevelopmental outcome in No-THOP infants reflected by significantly worse cognitive and motor outcomes at 2 years corrected age.

Sensitivity and specificity of General Movements Assessment for diagnostic accuracy of detecting cerebral palsy early in an Australian context.

AIM: The aim of this study was to calculate the sensitivity and specificity of the General Movements Assessment (GMA) for estimating diagnostic accuracy in detecting cerebral palsy (CP) in an Australian context by a newly established NSW rater network. METHODS: A prospective longitudinal cross-sectional study was conducted. The GMA was blind-rated from conventional video by two independent certified raters, blinded to medical history. A third rater resolved disagreements. High-risk population screening for CP using the GMA during the fidgety period (12-20 weeks) was carried out in four neonatal intensive care units and one CP service over a 30-month period (2012-2013). Participants were 259 high-risk infants. Sensitivity and specificity values were calculated with true positives defined as a confirmed diagnosis of CP from a medical doctor. RESULTS: Of the 259 infants assessed, 1-year follow-up data were available for 187. Of these, n = 48 had absent fidgety (high risk for CP), n = 138 had normal fidgety (low risk for CP), and n = 1 had abnormal fidgety (high risk for a neurological disorder). Of the 48 with absent fidgety movements, 39 had received a diagnosis of CP by 18 months and another 6 had an abnormal outcome. Of the n = 138 normal fidgety cases, n = 99 cases had a normal outcome, n = 38 had an abnormal outcome but not CP, and n = 1 had CP. For detecting CP, we had a sensitivity of 98% and specificity of 94%. CONCLUSION: GMA was feasible in an Australian context and accurately identified CP with a sensitivity and specificity comparable with European standards and published neuroimaging data.

Sensorimotor skills associated with motor dysfunction in children born extremely preterm.

BACKGROUND: Children born prematurely, despite being free of intellectual and sensorineural deficits, are at risk of motor dysfunction. AIM: To investigate the association of sensorimotor processing skills and Developmental Coordination Disorder (DCD) in "apparently normal" extreme preterm children. STUDY DESIGN: In a matched case-control study, 50 preterm children born less than 29 weeks or birthweight <1000 g, with an IQ>85 and no identified sensorineural disability, were assessed at 8 years of age along with 50 gender and birth date matched classroom controls born at full term. A battery of sensorimotor tests was administered, which examined visual-motor, visual perception, tactile perception, kinaesthesia, and praxis. RESULTS: For preterm children with DCD (n=21), significantly lower scores were found for the visual processing and praxis tests, with the exception of verbal command, in comparison to those 29 preterm children without DCD and term controls (median visual perception scores were 92, 96 and 108 respectively; design copying was 0.07, 0.46 and 0.95; constructive praxis was 0.09, 0.27 and 0.63; and sequencing praxis was 0.14, 0.73 and 0.96). There were no difference on the tactile sensitivity and kinaesthetic processing tests. CONCLUSIONS: Preterm children with DCD have difficulty with visual processing tasks. Praxis or motor planning poses a particular challenge for them. Motor dysfunction in extremely preterm children was related to poorer visual processing and motor planning and may relate to a cognitive processing problem.

Reliability and validity of the Evaluation Tool of Children's Handwriting-Cursive (ETCH-C) using the general scoring criteria.

OBJECTIVES: To determine the reliability and aspects of validity of the Evaluation Tool of Children's Handwriting-Cursive (ETCH-C; Amundson, 1995), using the general scoring criteria, when assessing children who use alternative writing scripts. METHOD: Children in Years 5 and 6 with handwriting problems and a group of matched control participants from their respective classrooms were assessed with the ETCH-C twice, 4 weeks apart. RESULTS: Total Letter scores were most reliable; more variability should be expected for Total Word scores. Total Numeral scores showed unacceptable reliability levels and are not recommended. We found good discriminant validity for Letter and Word scores and established cutoff scores to distinguish children with and without handwriting dysfunction (Total Letter <90%, Total Word <85%). CONCLUSION: The ETCH-C, using the general scoring criteria, is a reliable and valid test of handwriting for children using alternative scripts.

Developmental outcome of discordant premature twins at 3 years.

BACKGROUND: There are numerous known or unknown maternal, fetal and intrauterine conditions that may lead to growth restriction. In addition to prematurity and growth restriction, developmental outcome may also be influenced by many genetic and environmental factors. AIM: To examine the impact of intrauterine growth restriction on development in premature discordant twins. STUDY DESIGN: Intra-pair control comparison. METHODS: Developmental outcome at age 3 years was examined in 21 pairs of discordant (>15% birth weight discordance) very low birth weight (VLBW) premature twins. RESULTS: None of the smaller twins had cerebral palsy and one larger twin had a mild diplegia. In paired comparisons, the smaller twins were somatically smaller and had a slight lower Griffiths' developmental quotient (GQ) than the co-twins without cerebral palsy [mean+/-S.D. 100+/-13, range 73-117, versus 104+/-12, 80-124, p=0.002]. The largest difference was in the locomotor subscale. There was a greater intra-pair GQ difference in the 12 twin pairs who had a discordance of greater than 30% (mean GQ=98 versus 105, p<0.001). The intra-pair GQ correlated well (r=0.90), a finding similar to that of a comparative group of 26 nondiscordant VLBW twin pairs (r=0.87). A multivariate analysis confirmed that gestation and percentage discordance were the important factors influencing GQ. CONCLUSION: There exists a strong influence of common intrauterine, genetic and environmental factors on developmental outcome. Despite an overall lack of adverse outcome in smaller twins, results indicated a small but significant influence of growth restriction.

Longitudinal motor development of "apparently normal" high-risk infants at 18 months, 3 and 5 years.

BACKGROUND: Motor development appears to be more affected by premature birth than other developmental domains, however few studies have specifically investigated the development of gross and fine motor skills in this population. AIM: To examine longitudinal motor development in a group of "apparently normal" high-risk infants. SETTING: Developmental follow-up clinic in a perinatal centre. STUDY DESIGN: Longitudinal observational cohort study. SUBJECTS: Fifty-eight infants born less than 29 weeks gestation and/or 1000 g and without disabilities detected at 12 months. OUTCOME MEASURES: Longitudinal gross and fine motor skills at 18 months, 3 and 5 years using the Peabody Developmental Motor Scales. The HOME scale provided information of the home environment as a stimulus for development. RESULTS: A large proportion (54% at 18 months, 47% at 3 years and 64% at 5 years) of children continued to have fine motor deficits from 18 months to 5 years. The proportion of infants with gross motor deficits significantly increased over this period (14%, 33% and 81%, p<0.001), particularly for the 'micropreemies' (born <750 g). In multivariate analyses, gross motor development was positively influenced by the quality of the home environment. CONCLUSIONS: A large proportion of high-risk infants continued to have fine motor deficits, reflecting an underlying problem with fine motor skills. The proportion of infants with gross motor deficits significantly increased, as test demands became more challenging. In addition, the development of gross and fine motor skills appears to be influenced differently by the home environment.