Upper Airway Pathology Contributes to Respiratory Symptoms in Children Born Very Preterm.

OBJECTIVE: To evaluate the role of upper airway dysfunction, indicated by altered vocal quality (dysphonia), on the respiratory symptoms of children surviving very preterm birth. STUDY DESIGN: Children born <32 weeks of gestation participated in 2 separate assessments during midchildhood. The first visit assessed voice quality by a subjective evaluation using the Consensus Auditory-Perceptual Evaluation of Voice and a computerized analysis of the properties of the voice via the Acoustic Voice Quality Index. The second assessment recorded parentally reported respiratory symptoms and measures of lung function, including spirometry, lung volumes, oscillatory mechanics, and a cardiopulmonary exercise test. RESULTS: Preterm children (n = 35; median gestation 24.3 weeks) underwent paired voice and lung assessments at approximately 11 years of age. Preterm children with dysphonia (n = 25) reported significantly more respiratory symptoms than those with normal voices (n = 10) including wheeze (92% vs 40%; P = .001) and asthma diagnosed by a physician (60% vs 10%; P = .007). Lung function outcomes were generally not different between the dysphonic group and the group with normal voice (P > .05), except for the oscillatory mechanics measures, which were all at least 0.5 z score lower in the dysphonic group (Xrs8 mean difference = -0.91 z scores, P = .003; fres = 1.06 z scores, P = .019; AX = -0.87 z scores, P = .010; Rrs8 = 0.63 z scores, P = .068). CONCLUSIONS: The upper airway may play a role in the respiratory symptoms experienced by some very preterm children and should be considered by clinicians, especially when symptoms are in the presence of normal lung function and are refractory to treatment.

Docosahexaenoic acid supplementation of preterm infants and parent-reported symptoms of allergic disease at 7 years corrected age: follow-up of a randomized controlled trial.

BACKGROUND: Docosahexaenoic acid (DHA, 22:6n-3) supplementation in the prenatal period is associated with a reduction in the incidence of some symptoms of allergic disease. Infants born preterm are at increased risk of allergic disease, but it is unknown if DHA supplementation reduces the risk of childhood allergies. OBJECTIVES: The aim of this study was to determine if supplementation of infants born at <33 wk gestation with high-DHA compared with standard-DHA enteral feeds decreases the incidence and severity of parent-reported allergic disease symptoms at a corrected age (CA) of 7 y. METHODS: This study was a follow-up of an Australian multicenter randomized controlled trial. Infants were given high-DHA (∼1% total fatty acids) or standard-DHA (∼0.3% total fatty acids) enteral feeds from 2-4 d of postnatal age until 40 wk postmenstrual age. Parent-reported incidence of respiratory allergic disease symptoms including wheeze and rhinitis at 7 y CA were the main outcomes. Other outcomes included the incidence of eczema symptoms; severity of any symptoms; and the incidence of wheeze, rhinitis, rhinoconjunctivitis, and eczema from birth to 7 y CA. RESULTS: Data were available for 569 of 657 (87%) children originally randomized. Symptoms of wheeze or rhinitis at 7 y CA did not differ between high- and standard-DHA groups [wheeze: RR: 1.10; 95% CI: 0.73, 1.65; P = 0.66; rhinitis: RR: 1.09; 95% CI: 0.81, 1.46; P = 0.59]. There was no difference in other allergic disease symptoms at 7 y CA or in the severity of symptoms. Parent-reported symptoms of wheeze, rhinitis, rhinoconjunctivitis, or eczema from birth to 7 y CA did not differ between the groups. CONCLUSIONS: High-dose DHA supplementation of infants born at <33 wk gestation did not alter allergic disease symptoms or severity at 7 y CA, or from birth to 7 y CA compared with standard-dose DHA. This trial was registered with the Australian New Zealand Clinical Trials Registry as ANZCTR 12606000327583 (http://www.anzctr.org.au).

Histological chorioamnionitis and developmental outcomes in very preterm infants.

OBJECTIVE: To characterize the association of histological chorioamnionitis (HCA) with neurodevelopmental outcomes in children born at <30 weeks gestation. STUDY DESIGN: This retrospective cohort study included infants born 2006-2012 in whom placental histopathology, neonatal outcomes, and Bayley-III assessment at age 2 years were available. We assessed the association of HCA exposure with cognitive, language, and motor delay with logistic regression models adjusted for gestational age, sex, small for gestational age and brain injury. RESULTS: Of 1353 infants, 985 had histological and neonatal data available, and 708 infants had Bayley-III assessments. HCA-exposed infants were at higher risk of some neonatal adverse outcomes, and stage of HCA correlated with low Apgar score and early-onset sepsis. Exposure to HCA was not associated with neurodevelopmental outcomes in adjusted models including stage of HCA. CONCLUSIONS: Exposure to HCA, especially higher stage, was associated with neonatal morbidity but not with adverse neurodevelopmental outcomes at 2 years of age.

Cognitive outcomes in children and adolescents born very preterm: a meta-analysis.

AIM: To estimate the association between very preterm birth (<32wks' gestation) and intelligence, executive functioning, and processing speed throughout childhood and adolescence, and to examine the effects of gestational age, birthweight, and age at assessment. METHOD: Studies were included if children were born at earlier than 32 weeks' gestation, aged 4 to 17 years, had an age-matched term control group, and if the studies used standardized measures, were published in an English-language peer-reviewed journal, and placed no restrictions on participants based on task performance. RESULTS: We evaluated 6163 children born very preterm and 5471 term-born controls from 60 studies. Children born very preterm scored 0.82 SDs (95% confidence interval [CI] 0.74-0.90; p<0.001) lower on intelligence tests, 0.51 SDs (95% CI 0.44-0.58; p<0.001) lower on measures of executive functioning, and 0.49 SDs (95% CI 0.39-0.60; p<0.001) lower on measures of processing speed than term-born controls. Gestational age and birthweight were associated with study effect size in intelligence and executive functioning of younger children only. Age at assessment was not associated with study effect size. INTERPRETATION: Children born very preterm have medium to large deficits in these cognitive domains. WHAT THIS PAPER ADDS: This meta-analysis is centred on very preterm birth and three cognitive domains. The three critical cognitive domains are intelligence, executive functioning, and processing speed.

Survival and neurodevelopmental outcomes in extremely preterm infants 22-24 weeks of gestation born in Western Australia.

AIM: The management of births at borderline viability continues to present dilemmas for health professionals and parents. The aim of the study was to review local outcomes of infants born between 22 and 24 weeks of gestation between 2004 and 2010 in Western Australia (WA) to aid perinatal counselling. METHODS: Survival data for the study were sourced retrospectively from the Neonatal Clinical Care Unit and Department of Health records of births in WA. Neurodevelopmental follow-up outcomes were assessed using the most recent standardised assessment (Griffiths, Bayley-III and Wechsler Preschool and Primary Scale of Intelligence, 3rd Ed) and medical examination of infants/children 12 months to 8 years from follow-up clinic appointments. RESULTS: At these gestations, 159 survivors represented 72% of neonatal intensive care unit admissions, 53% of WA live births and 26% of WA live and still births; 5% of live births survived at 22 weeks, 46% at 23 weeks and 77% at 24 weeks. Of the 14 outborn/retrieved infants, 4 survived (29%). At a median age of 59 months, disabilities were severe in 13% of children (22-23w = 19%; 24w = 11%). The median test quotient was 90. Moderate and severe cognitive disability was found in 16%, cerebral palsy was found in 7% (n = 11), and 55% of children were free from impairment as defined in this study. CONCLUSION: At these gestations, survival figures varied markedly with the chosen population denominator. Regional data are essential for valid population comparison. While many developmental difficulties occurred in these children, 78% were free from moderate or severe impairment at ages 3-5 years.

The relationship between sleep problems and working memory in children born very preterm.

In two studies, the relationship between sleep and working memory performance was investigated in children born very preterm (i.e., gestation less than 32 weeks) and the possible mechanisms underlying this relationship. In Study 1, parent-reported measures of snoring, night-time sleep quality, and daytime sleepiness were collected on 89 children born very preterm aged 6 to 7 years. The children completed a verbal working memory task, as well as measures of processing speed and verbal storage capacity. Night-time sleep quality was found to be associated with verbal working memory performance over and above the variance associated with individual differences in processing speed and storage capacity, suggesting that poor sleep may have an impact on the executive component of working memory. Snoring and daytime sleepiness were not found to be associated with working memory performance. Study 2 introduced a direct measure of executive functioning and examined whether sleep problems would differentially impact the executive functioning of children born very preterm relative to children born to term. Parent-reported sleep problems were collected on 43 children born very preterm and 48 children born to term (aged 6 to 9 years). Problematic sleep was found to adversely impact executive functioning in the very preterm group, while no effect of sleep was found in the control group. These findings implicate executive dysfunction as a possible mechanism by which problematic sleep adversely impacts upon cognition in children born very preterm, and suggest that sleep problems can increase the cognitive vulnerability already experienced by many of these children.

Assessing hemispheric specialization for processing arithmetic skills in adults: A functional transcranial doppler ultrasonography (fTCD) study.

BACKGROUND: A major model of the cerebral circuits that underpin arithmetic calculation is the triple-code model of numerical processing. This model proposes that the lateralization of mathematical operations is organized across three circuits: a left-hemispheric dominant verbal code; a bilateral magnitude representation of numbers and a bilateral Arabic number code. NEW METHOD: This study simultaneously measured the blood flow of both middle cerebral arteries using functional transcranial Doppler ultrasonography to assess hemispheric specialization during the performance of both language and arithmetic tasks. The propositions of the triple-code model were assessed in a non-clinical adult group by measuring cerebral blood flow during the performance of multiplication and subtraction problems. Participants were 17 adults aged between 18-27 years. We obtained laterality indices for each type of mathematical operation and compared these in participants with left-hemispheric language dominance. It was hypothesized that blood flow would lateralize to the left hemisphere during the performance of multiplication operations, but would not lateralize during the performance of subtraction operations. RESULTS: Hemispheric blood flow was significantly left lateralized during the multiplication task, but was not lateralized during the subtraction task. COMPARISON WITH EXISTING METHOD(S): Compared to high spatial resolution neuroimaging techniques previously used to measure cerebral lateralization, functional transcranial Doppler ultrasonography is a cost-effective measure that provides a superior temporal representation of arithmetic cognition. CONCLUSIONS: These results provide support for the triple-code model of arithmetic processing and offer complementary evidence that multiplication operations are processed differently in the adult brain compared to subtraction operations.

Poorer divided attention in children born very preterm can be explained by difficulty with each component task, not the executive requirement to dual-task.

Children born very preterm (VP, ≤ 32 weeks) exhibit poor performance on tasks of executive functioning. However, it is largely unknown whether this reflects the cumulative impact of non-executive deficits or a separable impairment in executive-level abilities. A dual-task paradigm was used in the current study to differentiate the executive processes involved in performing two simple attention tasks simultaneously. The executive-level contribution to performance was indexed by the within-subject cost incurred to single-task performance under dual-task conditions, termed dual-task cost. The participants included 77 VP children (mean age: 7.17 years) and 74 peer controls (mean age: 7.16 years) who completed Sky Search (selective attention), Score (sustained attention) and Sky Search DT (divided attention) from the Test of Everyday Attention for Children. The divided-attention task requires the simultaneous performance of the selective- and sustained-attention tasks. The VP group exhibited poorer performance on the selective- and divided-attention tasks, and showed a strong trend toward poorer performance on the sustained-attention task. However, there were no significant group differences in dual-task cost. These results suggest a cumulative impact of vulnerable lower-level cognitive processes on dual-tasking or divided attention in VP children, and fail to support the hypothesis that VP children show a separable impairment in executive-level abilities.

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.

Poor executive functioning in children born very preterm: Using dual-task methodology to untangle alternative theoretical interpretations.

Two alternative theoretical explanations have been proposed for the difficulties with executive functioning observed in children born very preterm (VP; ⩽32 weeks): a general vulnerability (i.e., in attentional and processing capacities), which has a cascading impact on increasingly complex cognitive functions, and a selective vulnerability in executive-level cognitive processes. It is difficult to tease apart this important theoretical distinction because executive functioning tasks are, by default, complex tasks. In the current study, an experimental dual-task design was employed to control for differences in task difficulty in order to isolate executive control. Participants included 50 VP children (mean age=7.29 years) and 39 term peer controls (mean age=7.28 years). The VP group exhibited a greater dual-task cost relative to controls despite experimental control for individual differences in baseline ability on the component single tasks. This group difference also remained under a condition of reduced task difficulty. These results suggest a selective vulnerability in executive-level processes that can be separated from any general vulnerability.

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.

Haemophilus influenzae: a potent perinatal pathogen disproportionately isolated from Indigenous women and their neonates.

BACKGROUND: Nontypeable Haemophilus influenzae (NTHi) bacteraemia in pregnant women is strongly associated with pregnancy loss and preterm delivery. However, the clinical significance of isolation of NTHi from nonsterile sites is unknown. AIMS: To examine the hypothesis that isolation of NTHi from any specimen is associated with adverse perinatal outcomes and to investigate the impression that NTHi is disproportionately isolated from indigenous women and their neonates. MATERIALS AND METHODS: Cases where NTHi was isolated from maternal, fetal or neonatal specimens during the period from 1 July 1997 to 1 July 2009 were identified. Demographic and clinical data were extracted from case notes. Histopathological material was re-reviewed by a perinatal pathologist. Demographic and clinical features of the affected group were compared with the hospital obstetric population. RESULTS: NTHi was isolated from maternal, fetal or neonatal specimens in 97 pregnancies. Two women had NTHi isolated during different pregnancies. Two mothers and 10 neonates were bacteraemic. Indigenous women comprised 28% of pregnancies where NTHi was isolated, compared with 6% of the hospital obstetric population (P < 0.001). Pregnancy loss occurred in six cases (6%). Median gestation at delivery was 33 weeks. Of 96 liveborn neonates, 88 (92%) required admission to a neonatal special care unit. Four liveborn neonates died (4%). Chorioamnionitis was confirmed by histology in 31/33 (93.9%) of placentas examined. CONCLUSIONS: Isolation of NTHi occurred more commonly in indigenous women and neonates. Isolation of NTHi from any obstetric or neonatal specimen is associated with chorioamnionitis, preterm birth, pregnancy loss, early-onset neonatal sepsis and neonatal death.

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.

How do you think she feels? Vulnerability in empathy and the role of attention in school-aged children born extremely preterm.

The aim of this study was to examine empathic competence in children born extremely preterm (EP, <28 weeks) given vulnerabilities in social relationships. Empathy in typically developing children is mediated by executive functions. Executive functioning is also impaired in preterm children. Of particular interest in this study are the attentional components of executive functioning as mediators of empathic development. Thirty-two 7-year-old EP children and 40 age-matched term children participated in the Project K.I.D.S program and completed the Kids Empathy Development Scale (KEDS), Wechsler Intelligence Scale for Children (WISC-IV), and Test of Everyday Attention for Children (TEA-Ch). Children born extremely preterm exhibited poorer performance on all measures. The mediating role of attention in empathy competence was not supported by mediation modelling when FSIQ was controlled. As predicted, the EP group showed weaker empathic development relative to typically developing children. They also showed poorer attentional abilities. However, the effect of preterm birth on empathy was not mediated by executive-level attention. The cognitive mechanisms underpinning poor empathy competence in EP children remain unclear. Future research needs to examine the role of inhibition, social-emotional recognition, and regulation.

Neurodevelopmental outcomes at 7†years' corrected age in preterm infants who were fed high-dose docosahexaenoic acid to term equivalent: a follow-up of a randomised controlled trial.

OBJECTIVE: To determine if improvements in cognitive outcome detected at 18 months' corrected age (CA) in infants born <33 weeks' gestation receiving a high-docosahexaenoic acid (DHA) compared with standard-DHA diet were sustained in early childhood. DESIGN: Follow-up of a multicentre randomised controlled trial. Randomisation was stratified for sex, birth weight (<1250 vs ≥1250 g) and hospital. SETTING: Five Australian tertiary hospitals from 2008 to 2013. PARTICIPANTS: 626 of the 657 participants randomised between 2001 and 2005 were eligible to participate. INTERVENTIONS: High-DHA (≈1% total fatty acids) enteral feeds compared with standard-DHA (≈0.3% total fatty acids) from age 2-4 days until term CA. PRIMARY OUTCOME: Full Scale IQ of the Wechsler Abbreviated Scale of Intelligence (WASI) at 7 years CA. Prespecified subgroup analyses based on the randomisation strata (sex, birth weight) were conducted. RESULTS: 604 (92% of the 657 originally randomised) consented to participate (291 high-DHA, 313 standard-DHA). To address missing data in the 604 consenting participants (22 for primary outcome), multiple imputation was performed. The Full Scale IQ was not significantly different between groups (high-DHA 98.3, SD 14.0, standard-DHA 98.5, SD 14.9; mean difference adjusted for sex, birthweight strata and hospital -0.3, 95% CI -2.9 to 2.2; p=0.79). There were no significant differences in any secondary outcomes. In prespecified subgroup analyses, there was a significant sex by treatment interaction on measures of parent-reported executive function and behaviour. Scores were within the normal range but girls receiving the high-DHA diet scored significantly higher (poorer outcome) compared with girls receiving the standard-DHA diet. CONCLUSIONS: Supplementing the diets of preterm infants with a DHA dose of approximately 1% total fatty acids from days 2-4 until term CA showed no evidence of benefit at 7 years' CA. TRIAL REGISTRATION NUMBER: Australian New Zealand Clinical Trials Registry: ACTRN12606000327583.

Improvement in long-term breastfeeding for very preterm infants.

INTRODUCTION: The extensive health benefits of breastfeeding preterm infants for both mother and infant have been widely reported. However, establishing and maintaining breastfeeding for very preterm (VP) infants remain challenging. The aim of this study was to examine changes in breastfeeding of VP infants over time. SUBJECTS AND METHODS: Breastfeeding questionnaires were administered to two cohorts of parents of VP infants (<32 weeks) cared for at the tertiary perinatal or surgical neonatal unit in Western Australia. Of these, 488 infants were included in cohort 1 (C1) (births from January 1, 1990 to June 30, 1992) and 253 in cohort 2 (C2) (from January 1, 2011 to September 14, 2012). RESULTS: More mothers (96.8%) initiated breastfeeding in C2 compared with those in C1 (65.6%) (p<0.001). Additionally, 41.4% of mothers in C2 breastfed for more than 6 months, relative to 25.8% in C1 (p<0.001). The benefits of breastfeeding were endorsed by more women in C2 (45.8%) compared with C1 (11.4%) (p<0.01). Reasons for stopping feeding remained largely consistent. CONCLUSIONS: Significant improvements were evident in the initiation and duration of breastfeeding of the VP infant over time. This improvement was associated with attitudinal shifts in mothers about the benefits of breastfeeding.

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.

Long term follow up of high risk children: who, why and how?

BACKGROUND: Most babies are born healthy and grow and develop normally through childhood. There are, however, clearly identifiable high-risk groups of survivors, such as those born preterm or with ill-health, who are destined to have higher than expected rates of health or developmental problems, and for whom more structured and specialised follow-up programs are warranted. DISCUSSION: This paper presents the results of a two-day workshop held in Melbourne, Australia, to discuss neonatal populations in need of more structured follow-up and why, in addition to how, such a follow-up programme might be structured. Issues discussed included the ages of follow-up, and the personnel and assessment tools that might be required. Challenges for translating results into both clinical practice and research were identified. Further issues covered included information sharing, best practice for families and research gaps. SUMMARY: A substantial minority of high-risk children has long-term medical, developmental and psychological adverse outcomes and will consume extensive health and education services as they grow older. Early intervention to prevent adverse outcomes and the effective integration of services once problems are identified may reduce the prevalence and severity of certain outcomes, and will contribute to an efficient and effective use of health resources. The shared long-term goal for families and professionals is to work toward ensuring that high risk children maximise their potential and become productive and valued members of society.

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).