Barriers to accessing and receiving antenatal care: Findings from interviews with Australian women experiencing disadvantage.

AIM: To identify the barriers associated with inadequate antenatal attendance by disadvantaged women in Australia and to further explore how these barriers are experienced by this population group. DESIGN: A qualitative descriptive study utilizing semi-structured interviews and thematic analysis. METHODS: Interviews were conducted with 11 pregnant women who self-identified as experiencing disadvantage, purposively sampled from a local government area of Victoria, Australia, characterized by socio-economic disadvantage. Data were collected from February to July 2019. RESULTS: Study participants reported a range of barriers to receiving timely and adequate antenatal care (ANC). For several women, a combination of personal (e.g., emotions, knowledge), health service provision (e.g., limited access to continuity of care provider and continuity of information, inflexible scheduling, difficulty travelling, staff attitudes), and broader social-contextual factors (e.g., financial situation, language, cultural norms) were ultimately insurmountable. Whereas some barriers were experienced as hassles or annoyances, others were unacceptable, overwhelming, or humiliating. CONCLUSION: Women experiencing disadvantage in Australia value ANC but face multiple and complex barriers that undermine timely and regular access. IMPLICATIONS FOR THE PROFESSION AND/PATIENT CARE: A wide range of strategies targeting barriers across multiple levels of the social-ecological environment are required if ANC attendance rates are to improve and ultimately redress existing health disparities. Various continuity of care models are well-placed to address many of the identified barriers and should be made more accessible to women, and particularly those women experiencing disadvantage. IMPACT: Antenatal care appointments promote the health of women and their babies during pregnancy, but for many women, particularly those experiencing disadvantage, access is delayed or inadequate. ANC providers play a critical role in facilitating timely and adequate care. Health service practitioners and management, and health services policymakers need to understand the complexity of the barriers women encounter. These stakeholders can utilize the findings reported herein to develop more effective strategies for overcoming multiple and multi-level barriers. REPORTING METHOD: The study is reported in accordance with the relevant EQUATOR guidelines: the standards for reporting qualitative research (SRQR) and consolidated criteria for reporting qualitative research (COREQ). PATIENT OR PUBLIC CONTRIBUTION: No patient or public contribution.

Early Childhood Education Participation: A Mixed-Methods Study of Parent and Provider Perceived Barriers and Facilitators.

Participation in high-quality early childhood education and care (ECEC) benefits children and society. Policy recognition of this manifests through government subsidy strategies to increase ECEC access in the years immediately preceding school. Yet despite this action, many children do not receive the recommended amount. This study utilizes a mixed-methods design to investigate ECEC participation barriers and facilitators in three Australian communities. Parents and service providers completed online questionnaires (45 parents, 63 providers) and semi-structured interviews (21 parents, 16 providers). Results showed that issues related to both direct (e.g., fees) and indirect (e.g., travel) costs are particularly important barriers for families, and are well-recognized by providers. A range of factors were also considered important for facilitating participation (e.g., effective promotion of the benefits linked to high-quality play-based learning in formal settings, professional training of staff). Findings demonstrated the ecological complexity of participation. Strategies to address barriers and harness facilitators are required across multiple levels.

Systematic review: An exploration of core componentry characterizing effective sustained nurse home visiting programs.

AIMS: To identify the core components or potential 'active ingredients' of sustained nurse home visiting (SNHV) programs that have demonstrated positive effects on maternal or child health, psychosocial development, or self-sufficiency outcomes among disadvantaged families in high-income countries. DESIGN: Systematic review with narrative summary. DATA SOURCES: Programs were identified from searches of several reputable evidence clearing houses and the following bibliographic databases: Medline, Cumulative Index to Nursing and Allied Health Literature (CINAHL), PsycINFO, and Cochrane Central Register of Controlled Trials. Year of publication was originally restricted from 2008 -2018, with additional searches conducted up to 2019. REVIEW METHODS: This review of SNHV program componentry builds on a previous evaluation of program effectiveness. Programs were selected for inclusion if they had been tested in a randomized or cluster-randomized controlled trial (RCT/CRCT). Componentry characteristics related to program delivery, nurse provider, and outcome-specific intervention content were then extracted. RESULTS: Comparison of the seven eligible programs showed seven common core components: antenatal commencement, support to child age 2 years, at least 19 scheduled visits and experienced or highly qualified nurses with program-specific training, caseloads of approximately 25 families, regular supervision, and multidisciplinary supports. Outcome-specific program content was generally not well reported. CONCLUSION: The findings from this review have utility in guiding the development of minimum standard benchmarks and best-practice recommendations for SNHV programs and call for more detailed publication of core content componentry in the SNHV literature. IMPACT: Identification of the core componentry underpinning program effectiveness should inform policy decisions on program selection, adaptation for specific populations, and quality control. Such evidence-based decision-making should in turn lead to better maternal and child outcomes among disadvantaged families in high-income countries, reducing societal and economic burdens of inequity.

Sleep problems, internalizing and externalizing symptoms, and domains of health-related quality of life: bidirectional associations from early childhood to early adolescence.

STUDY OBJECTIVES: To examine longitudinal, bidirectional associations among behavioral sleep problems, internalizing and externalizing symptoms, and domains of health-related quality of life (HRQoL) from early childhood to adolescence in a population sample of Australian children. METHOD: Data were drawn from the Longitudinal Study of Australian Children, a national prospective cohort study with 4983 children participating in the Kindergarten cohort. Data were collected when children were aged 4-5, 6-7, 8-9, 10-11, and 12-13 years. At each study wave, the primary parent (97% mothers) reported on behavioral child sleep problems, internalizing and externalizing symptoms, and HRQoL domains (psychosocial and physical). Cross-lagged structural equation models were used to evaluate bidirectional associations. RESULTS: At nearly every age, behavioral sleep problems were associated with worse subsequent psychosocial and physical HRQoL. Despite bidirectional associations between mental health and HRQoL at many waves, HRQoL domains more strongly predicted later internalizing symptoms, while externalizing symptoms more strongly predicted later HRQoL. Many of the bidirectional associations among sleep, mental health, and HRQoL were found earlier in childhood. CONCLUSIONS: Behavioral sleep problems may forecast later HRQoL psychosocial and physical impairments. Attending to both sleep problems and HRQoL could prevent the progression of internalizing conditions, while a focus on externalizing concerns could prevent the worsening of these symptoms, sleep problems, and HRQoL, particularly during the transition to school.

A Novel 3-Part Approach to Tackle the Problem of Health Inequities in Early Childhood.

The first 5 years of a child's life are crucial in laying the foundation for their health and developmental trajectory into adulthood. These early years are especially influenced by the surrounding environments in which children live and grow. A large international body of evidence demonstrates that children who experience disadvantage tend to fall increasingly behind over time. At the societal level, these inequities can cause substantial social burdens and significant costs across health, education, and welfare budgets. A contributing factor is that children experiencing adversity are less likely to have access to the environmental conditions that support them to thrive. Many of these factors are modifiable at the community or place level. We argue for three key-though not exhaustive-ideas that collectively could achieve more equitable outcomes for children facing disadvantage and experiencing adversity:We conclude that if adopted, these 3 ideas could contribute to the ability of local communities and networks to identify and respond to factors that address early childhood inequalities.

Systematic review: Effects of sustained nurse home visiting programs for disadvantaged mothers and children.

AIMS: To systematically evaluate published experimental studies of sustained nurse home visiting (SNHV) programs. This review summarizes the evidence and identifies gaps in the literature to inform practice, policy, and future research. DESIGN: Restricted systematic review with narrative summary. DATA SOURCES: Databases searched were Medline, CINAHL, PsycINFO, and Cochrane Central Register of Controlled Trials. Year of publication was originally restricted from 2008 to the date of search (13 February 2018, with supplementary searches conducted to identify more recent publications (up to 2019). Several reputable evidence clearinghouses were also searched. REVIEW METHODS: Studies were included if they used a randomized or cluster-randomized controlled trial to evaluate a home visiting program that: (a) targeted disadvantaged mothers; (b) commenced during pregnancy or prior to the child's first birthday; (c) had an intended duration of at least 12 months from the time of enrolment; and (d) was substantively delivered by nurses or midwives. Meta-analyses and reviews of studies meeting these criteria were also included. A quality appraisal was conducted for all studies. RESULTS: Of 1,393 total articles, 30 met inclusion criteria. Seven specific SNHV programs were identified. Each demonstrated evidence of a positive statistical effect on at least one child or maternal outcome. CONCLUSION: Sustained nurse home visiting programs benefit disadvantaged families, though effects vary across outcomes and subgroups. Further research is needed to discern the critical components of effective programs. IMPACT: As SNHV programs have gained policy appeal, the need to evaluate the evidence-base supporting such interventions has become imperative. The findings of this review will assist policy-makers and practitioners in high-income countries to make evidence-informed decisions about which programs are best suited to addressing specific maternal and child outcomes for disadvantaged families. This should in turn ameliorate some of the inequalities in child development that have significant social and economic costs.

Health service utilisation and unmet healthcare needs of Australian children from immigrant families: A population-based cohort study.

Compared with most other Organization for Economic Co-operation and Development (OECD) countries, information about the patterns of health service use for children from immigrant families in Australia is currently limited, and internationally, data on unmet healthcare needs are scarce. This study aims to examine the distribution of health service utilisation and unmet healthcare needs for immigrant children aged 10-11 years in Australia. We drew on data from the Longitudinal Study of Australian Children Birth (B; n = 5,107) and Kindergarten (K; n = 4,983) cohorts. The exposure was family immigration background collected at 0-1 (B-cohort) and 4-5 (K-cohort) years. Outcomes were parent-reported child health service use and unmet healthcare needs (defined as the difference between services needed and services received) at 10-11 years. Logistic regression analyses were used to examine associations between family immigration background and health service use/unmet healthcare needs, adjusting for potential confounders. Results showed that one-third of Australian children (B-cohort: 29.0%; K-cohort: 33.4%) came from immigrant families. There were similar patterns of health service use and unmet healthcare needs between children from English-speaking immigrant and Australian-born families. However, children from non-English-speaking immigrant families used fewer health services, including paediatric, dental, mental health and emergency ward services. There was a disparity between the services used when considering children's health needs, particularly for paediatric specialist services (B-cohort: OR = 2.43, 95% CI 1.11-5.31; K-cohort: OR = 2.72, 95% CI 1.32-5.58). Findings indicate that Australian children from non-English-speaking immigrant families experience more unmet healthcare needs and face more barriers in accessing health services. Further effort is needed to ensure that the healthcare system meets the needs of all families.

Brief evidence-based interventions for universal child health services: a restricted evidence assessment of the literature.

BACKGROUND: Universal child health services (UCHS) provide an important pragmatic platform for the delivery of universal and targeted interventions to support families and optimize child health outcomes. We aimed to identify brief, evidence-based interventions for common health and developmental problems that could be potentially implemented in UCHS. METHODS: A restricted evidence assessment (REA) of electronic databases and grey literature was undertaken covering January 2006 to August 2019. Studies were eligible if (i) outcomes related to one or more of four areas: child social and emotional wellbeing (SEWB), infant sleep, home learning environment or parent mental health, (ii) a comparison group was used, (iii) universal or targeted intervention were delivered in non-tertiary settings, (iv) interventions did not last more than 4 sessions, and (v) children were aged between 2 weeks postpartum and 5 years at baseline. RESULTS: Seventeen studies met the eligibility criteria. Of these, three interventions could possibly be implemented at scale within UCHS platforms: (1) a universal child behavioural intervention which did not affect its primary outcome of infant sleep but improved parental mental health, (2) a universal screening programme which improved maternal mental health, and (3) a targeted child behavioural intervention which improved parent-reported infant sleep problems and parental mental health. Key lessons learnt include: (1) Interventions should impart the maximal amount of information within an initial session with future sessions reinforcing key messages, (2) Interventions should see the family as a holistic unit by considering the needs of parents with an emphasis on identification, triage and referral, and (3) Brief interventions may be more acceptable for stigmatized topics, but still entail considerable barriers that deter the most vulnerable. CONCLUSIONS: Delivery and evaluation of brief evidence-based interventions from a UCHS could lead to improved maternal and child health outcomes through a more responsive and equitable service. We recommend three interventions that meet our criteria of "best bet" interventions.

Potential of 'stacking' early childhood interventions to reduce inequities in learning outcomes.

BACKGROUND: Early childhood interventions are critical for reducing child health and development inequities. While most research focuses on the efficacy of single interventions, combining multiple evidence-based strategies over the early years of a child's life may yield greater impact. This study examined the association between exposure to a combination of five evidence-based services from 0 to 5 years on children's reading at 8-9 years. METHODS: Data from the nationally representative birth cohort (n=5107) of the Longitudinal Study of Australian Children were utilised. Risk and exposure measures across five services from 0 to 5 years were assessed: antenatal care, nurse home-visiting, early childhood education and care, parenting programme and the early years of school. Children's reading at 8-9 years was measured using a standardised direct assessment. Linear regression analyses examined the cumulative effect of five services on reading. Interaction terms were examined to determine if the relationship differed as a function of level of disadvantage. RESULTS: A cumulative benefit effect of participation in more services and a cumulative risk effect when exposed to more risks was found. Each additional service that the child attended was associated with an increase in reading scores (b=9.16, 95% CI=5.58 to 12.75). Conversely, each additional risk that the child was exposed to was associated with a decrease in reading skills (b=-14.03, 95% CI=-16.61 to -11.44). Effects were similar for disadvantaged and non-disadvantaged children. CONCLUSION: This study supports the potential value of 'stacking' early interventions across the early years of a child's life to maximise impacts on child outcomes.

The contribution of visual processing to academic achievement in adolescents born extremely preterm or extremely low birth weight.

Children born extremely preterm (EP, <28 weeks) and/or extremely low birth weight (ELBW, <1000 g) have more academic deficiencies than their term-born peers, which may be due to problems with visual processing. The aim of this study is to determine (1) if visual processing is related to poor academic outcomes in EP/ELBW adolescents, and (2) how much of the variance in academic achievement in EP/ELBW adolescents is explained by visual processing ability after controlling for perinatal risk factors and other known contributors to academic performance, particularly attention and working memory. A geographically determined cohort of 228 surviving EP/ELBW adolescents (mean age 17 years) was studied. The relationships between measures of visual processing (visual acuity, binocular stereopsis, eye convergence, and visual perception) and academic achievement were explored within the EP/ELBW group. Analyses were repeated controlling for perinatal and social risk, and measures of attention and working memory. It was found that visual acuity, convergence and visual perception are related to scores for academic achievement on univariable regression analyses. After controlling for potential confounds (perinatal and social risk, working memory and attention), visual acuity, convergence and visual perception remained associated with reading and math computation, but only convergence and visual perception are related to spelling. The additional variance explained by visual processing is up to 6.6% for reading, 2.7% for spelling, and 2.2% for math computation. None of the visual processing variables or visual motor integration are associated with handwriting on multivariable analysis. Working memory is generally a stronger predictor of reading, spelling, and math computation than visual processing. It was concluded that visual processing difficulties are significantly related to academic outcomes in EP/ELBW adolescents; therefore, specific attention should be paid to academic remediation strategies incorporating the management of working memory and visual processing in EP/ELBW children.

School-Age Outcomes of Early Intervention for Preterm Infants and Their Parents: A Randomized Trial.

OBJECTIVE: To examine the child and parental outcomes at school age of a randomized controlled trial of a home-based early preventative care program for infants born very preterm and their caregivers. METHODS: At term-equivalent age, 120 infants born at a gestational age of <30 weeks were randomly allocated to intervention (n = 61) or standard care (n = 59) groups. The intervention included 9 home visits over the first year of life focusing on infant development, parental mental health, and the parent-infant relationship. At 8 years' corrected age, children's cognitive, behavioral, and motor functioning and parental mental health were assessed. Analysis was by intention to treat. RESULTS: One hundred children, including 13 sets of twins, attended follow-up (85% follow-up of survivors). Children in the intervention group were less likely to have mathematics difficulties (odds ratio, 0.42; 95% confidence interval [CI], 0.18 to 0.98; P = .045) than children in the standard care group, but there was no evidence of an effect on other developmental outcomes. Parents in the intervention group reported fewer symptoms of depression (mean difference, -2.7; 95% CI, -4.0 to -1.4; P < .001) and had reduced odds for mild to severe depression (odds ratio, 0.14; 95% CI, 0.03 to 0.68; P = .0152) than parents in the standard care group. CONCLUSIONS: An early preventive care program for very preterm infants and their parents had minimal long-term effects on child neurodevelopmental outcomes at the 8-year follow-up, whereas primary caregivers in the intervention group reported less depression.

Long-term effect of high-dose supplementation with DHA on visual function at school age in children born at <33 wk gestational age: results from a follow-up of a randomized controlled trial.

BACKGROUND: Children born preterm are at risk of visual-processing impairments. Several lines of evidence have contributed to the rationale that docosahexaenoic acid (DHA) supplementation of preterm infants may improve outcomes in visual processing. OBJECTIVE: The aim was to determine whether at 7 y of age children who were born very preterm and who received a high-DHA diet have better visual-processing outcomes than do infants fed a standard-DHA diet. DESIGN: This was a follow-up study in a subgroup of children from a randomized controlled trial. Infants were randomly assigned to milk containing a higher concentration of DHA (1% of total fatty acids; high-DHA group) or a standard amount of DHA (0.2-0.3% of total fatty acids as DHA; control group). The randomization schedule was stratified by sex and birth weights of <1250 or ≥1250 g. A total of 104 (49 in the high-DHA group and 55 in the standard-DHA group) children aged 7 y were assessed on a range of visual-processing measures, including visual acuity, contrast sensitivity, vernier acuity, binocular stereopsis, and visual perception. RESULTS: There was no evidence of differences between the high-DHA and standard-DHA groups in any of the visual-processing measures. In the majority (12 of 13) of variables assessed, the direction of effect favored the control group. The study was large enough to detect a moderate treatment effect, if one truly existed. CONCLUSION: Supplementing human milk with DHA at a dose of ∼1% of total fatty acids given in the first months of life to very preterm infants does not appear to confer any long-term benefit for visual processing at school age. This trial was registered at anzctr.org/au as ACTRN12606000327583.

The long-term outcome of extremely preterm (<28 weeks' gestational age) infants with and without severe retinopathy of prematurity.

BACKGROUND: Severe retinopathy of prematurity (ROP) is associated with an increased risk for ophthalmologic morbidity, but the long-term impact in other domains is less clear. The aim of the current study was to determine whether severe ROP was related to poorer visual, cognitive, and educational outcomes in a representative sample of EP adolescents, and whether this persisted after adjusting for confounding neonatal risk factors. METHOD: One hundred and eighty extremely preterm (EP; <28 weeks) adolescents (17-18 years) were assessed on a range of neurodevelopmental measures, including visual processing, IQ, visual learning, visual-motor integration, and academic achievement. EP adolescents were grouped according to ROP status, (1) severe ROP (stage 3 or greater) in the worse eye; or (2) no or mild ROP and were compared on each outcome. Longitudinal data were compared at 2, 5, 8, and 17-18 years for general cognitive outcome. RESULTS: The severe ROP group performed more poorly and had more impairments than the non-severe ROP group on measures of visual processing, visual-motor integration, visual learning, IQ, and some academic achievement tests at 17-18 years of age. Group differences diminished after controlling for perinatal risk factors (severe white matter injury, post-natal corticosteroid, and surgery in the neonatal period), and only visual acuity scores remained significantly different between the groups. IQ scores remained consistently lower in the severe ROP group over time, but the magnitude reduced after adjusting for perinatal risk factors. CONCLUSIONS: Extremely preterm children with severe ROP are at increased risk for ongoing visual processing difficulties and lower IQ compared with EP peers without severe ROP. While severe ROP is a predictor of long-term impairments, this association is largely mediated by other neonatal risk factors.

Neural correlates of impaired vision in adolescents born extremely preterm and/or extremely low birthweight.

BACKGROUND: Adolescents born extremely preterm (EP; <28 weeks' gestation) and/or extremely low birthweight (ELBW; <1000 g) experience high rates of visual impairments, however the potential neural correlates of visual impairments in EP/ELBW adolescents require further investigation. This study aimed to: 1) compare optic radiation and primary visual cortical structure between EP/ELBW adolescents and normal birthweight controls; 2) investigate associations between perinatal factors and optic radiation and primary visual cortical structure in EP/ELBW adolescents; 3) investigate associations between optic radiation and primary visual cortical structure in EP/ELBW adolescents and the odds of impaired vision. METHODS: 196 EP/ELBW adolescents and 143 controls underwent magnetic resonance imaging at a mean age of 18 years. Optic radiations were delineated using constrained spherical deconvolution based probabilistic tractography. Primary visual cortices were segmented using FreeSurfer software. Diffusion tensor variables and tract volume of the optic radiations, as well as volume, surface area and thickness of the primary visual cortices, were estimated. RESULTS: Axial, radial and mean diffusivities within the optic radiations, and primary visual cortical thickness, were higher in the EP/ELBW adolescents than controls. Within EP/ELBW adolescents, postnatal corticosteroid exposure was associated with altered optic radiation diffusion values and lower tract volume, while decreasing gestational age at birth was associated with increased primary visual cortical volume, area and thickness. Furthermore, decreasing optic radiation fractional anisotropy and tract volume, and increasing optic radiation diffusivity in EP/ELBW adolescents were associated with increased odds of impaired vision, whereas primary visual cortical measures were not associated with the odds of impaired vision. CONCLUSIONS: Optic radiation and primary visual cortical structure are altered in EP/ELBW adolescents compared with controls, with the greatest alterations seen in those exposed to postnatal corticosteroids and those born earliest. Structural alterations to the optic radiations may increase the risk of impaired vision in EP/ELBW adolescents.

Visual memory and learning in extremely low-birth-weight/extremely preterm adolescents compared with controls: a geographic study.

BACKGROUND: Contemporary data on visual memory and learning in survivors born extremely preterm (EP; <28 weeks gestation) or with extremely low birth weight (ELBW; <1,000 g) are lacking. METHODS: Geographically determined cohort study of 298 consecutive EP/ELBW survivors born in 1991 and 1992, and 262 randomly selected normal-birth-weight controls. RESULTS: Visual learning and memory data were available for 221 (74.2%) EP/ELBW subjects and 159 (60.7%) controls. EP/ELBW adolescents exhibited significantly poorer performance across visual memory and learning variables compared with controls. Visual learning and delayed visual memory were particularly problematic and remained so after controlling for visual-motor integration and visual perception and excluding adolescents with neurosensory disability, and/or IQ <70. Male EP/ELBW adolescents or those treated with corticosteroids had poorer outcomes. CONCLUSION: EP/ELBW adolescents have poorer visual memory and learning outcomes compared with controls, which cannot be entirely explained by poor visual perceptual or visual constructional skills or intellectual impairment.

Contribution of brain size to IQ and educational underperformance in extremely preterm adolescents.

OBJECTIVES: Extremely preterm (EP) survivors have smaller brains, lower IQ, and worse educational achievement than their term-born peers. The contribution of smaller brain size to the IQ and educational disadvantages of EP is unknown. This study aimed (i) to compare brain volumes from multiple brain tissues and structures between EP-born (< 28 weeks) and term-born (≥ 37 weeks) control adolescents, (ii) to explore the relationships of brain tissue volumes with IQ and basic educational skills and whether this differed by group, and (iii) to explore how much total brain tissue volume explains the underperformance of EP adolescents compared with controls. METHODS: Longitudinal cohort study of 148 EP and 132 term controls born in Victoria, Australia in 1991-92. At age 18, magnetic resonance imaging-determined brain volumes of multiple tissues and structures were calculated. IQ and educational skills were measured using the Wechsler Abbreviated Scale of Intelligence (WASI) and the Wide Range Achievement Test(WRAT-4), respectively. RESULTS: Brain volumes were smaller in EP adolescents compared with controls (mean difference [95% confidence interval] of -5.9% [-8.0, -3.7%] for total brain tissue volume). The largest relative differences were noted in the thalamus and hippocampus. The EP group had lower IQs(-11.9 [-15.4, -8.5]), spelling(-8.0 [-11.5, -4.6]), math computation(-10.3 [-13.7, -6.9]) and word reading(-5.6 [-8.8, -2.4]) scores than controls; all p-values<0.001. Volumes of total brain tissue and other brain tissues and structures correlated positively with IQ and educational skills, a relationship that was similar for both the EP and controls. Total brain tissue volume explained between 20-40% of the IQ and educational outcome differences between EP and controls. CONCLUSIONS: EP adolescents had smaller brain volumes, lower IQs and poorer educational performance than controls. Brain volumes of multiple tissues and structures are related to IQ and educational outcomes. Smaller total brain tissue volume is an important contributor to the cognitive and educational underperformance of adolescents born EP.

Attention difficulties in a contemporary geographic cohort of adolescents born extremely preterm/extremely low birth weight.

The aim of this study was to evaluate attention difficulties in a contemporary geographic cohort of adolescents born extremely preterm (EP, <28 weeks' gestation) or extremely low birth weight (ELBW, birth weight <1000 g). The EP/ELBW group included 228 adolescents (mean age = 17.0 years) born in Victoria, Australia in 1991 and 1992. The control group were 166 adolescents (mean age = 17.4 years) born of normal birth weight (birth weight >2499 g) who were recruited in the newborn period and matched to the EP/ELBW group on date of birth, gender, language spoken and health insurance status. Participants were assessed on measures of selective, sustained, and executive (shift and divided) attention, and parents and participants completed behavioral reports. The EP/ELBW group performed more poorly across tests of selective and executive attention, had greater rates of clinically significant difficulties compared with the control group, and also had greater behavioral attention problems as reported by parents. Neonatal risk factors were weakly associated with attention outcomes. In conclusion, higher rates of attention impairments are observed in individuals born EP/ELBW well into adolescence and may have consequences for their transition to adulthood.

Visual processing in adolescents born extremely low birth weight and/or extremely preterm.

BACKGROUND AND OBJECTIVES: Ocular growth and development differs between preterm and term-born infants and may cause long-term negative consequences for visual function, but contemporary data on long-term visual outcomes in representative samples of the highest risk extremely low birth weight (ELBW, <1000 g birth weight) or extremely preterm (EP, <28 weeks' gestation) survivors are lacking. Our objective was to compare visual functioning between ELBW/EP and normal birth weight (NBW, >2499 g birth weight) control adolescents. METHODS: Geographically determined cohort study of 228 consecutive ELBW/EP survivors born in the state of Victoria in 1991 and 1992, and 166 randomly selected NBW controls assessed between 14 and 20 years of age. Visual acuity, stereopsis, convergence, color perception, and visual perception were assessed and contrasted between groups. RESULTS: ELBW/EP subjects had significantly worse visual acuity with habitual correction in both the left and right eyes, and for the best eye (P < .001). The ELBW/EP adolescents also exhibited poorer stereopsis, odds ratio (OR) 3.22 (95% confidence interval [CI] 1.78 to 5.84), and convergence, OR 2.76 (CI 1.32 to 5.75) than controls, and more problems with visual perception, OR 3.09 (CI 1.67 to 5.71) after habitual correction. CONCLUSIONS: Despite advances in medical care improving the survival rate of high-risk ELBW/EP infants, visual morbidity is still relatively high compared with controls in late adolescence.

Docosahexaenoic acid and visual functioning in preterm infants: a review.

Preterm children are at risk for a number of visual impairments which can be important for a range of other more complex visuocognitive tasks reliant on visual information. Despite the relatively high incidence of visual impairments in this group there are no good predictors that would allow early identification of those at risk for adverse outcomes. Several lines of evidence suggest that docosahexaenoic acid (DHA) supplementation for preterm infants may improve outcomes in this area. For example, diets deficient in the long-chain polyunsaturated fatty acid DHA have been shown to reduce its concentration in the cerebral cortex and retina, which interferes with physiological processes important for cognition and visual functioning. Further, various studies with pregnant and lactating women, as well as formula-fed infants, have demonstrated a general trend that supplementation with dietary DHA is associated with better childhood outcomes on tests of visual and cognitive development over the first year of life. However, research to date has several methodological limitations, including concentrations of DHA supplementation that have been too low to emulate the in utero accretion of DHA, using single measures of visual acuity to make generalised assumptions about the entire visual system, and little attempt to match what we know about inadequate DHA and structural ramifications with how specific functions may be affected. The objective of this review is to consider the role of DHA in the context of visual processing with a specific emphasis on preterm infants and to illustrate how future research may benefit from marrying what we know about structural consequences to inadequate DHA with functional outcomes that likely have far-reaching ramifications. Factors worth considering for clinical neuropsychological evaluation are also discussed.