[Risk assessment of pre-term infants]. / Risiken bei Zustand nach Frühgeburt. Grundlagen für die medizinische Risikoprüfung.

Pre-term birth occurs when a baby is born before 37 weeks of gestation are completed. Many recent publications on neurodevelopmental and somatic outcome parameters of premature infants are of interest for insurance medicine. Infants born before the 28th week are called extremely pre-term. When examined at five years, 85% had already received or still needed special treatment or support. The results of examinations in early childhood have quite a low predictive value for the further development of the child. In the very and moderately pre-term stages, long-term risks are continuously declining with the length of gravidity. Even "late pre-term" birth (34 to 36 weeks of gestation) is associated with a nearly doubled rate of developmental impairment and chronic disease in childhood and adolescence. Various studies performed in early adulthood showed that former pre-term infants suffered more often from asthma and psychiatric disorders. On average, they also had higher blood pressure, lower insulin sensitivity, and a reduced exercise capacity. It remains to be evaluated how much these risk factors contribute to cardiovascular or pulmonary morbidity and mortality later in life. At least, general mortality after preterm birth seems to be increased up to the oldest age group statistically evaluated up to now, i.e. 18 to 36 years.

Association of postpartum maternal morbidities with children's mental, psychomotor and language development in rural Bangladesh.

Little is known from developing countries about the effects of maternal morbidities diagnosed in the postpartum period on children's development. The study aimed to document the relationships of such morbidities with care-giving practices by mothers, children's developmental milestones and their language, mental and psychomotor development. Maternal morbidities were identified through physical examination at 6-9 weeks postpartum (n=488). Maternal care-giving practices and postnatal depression were assessed also at 6-9 weeks postpartum. Children's milestones of development were measured at six months, and their mental (MDI) and psychomotor (PDI) development, language comprehension and expression, and quality of psychosocial stimulation at home were assessed at 12 months. Several approaches were used for identifying the relationships among different maternal morbidities, diagnosed by physicians, with children's development. After controlling for the potential confounders, maternal anaemia diagnosed postpartum showed a small but significantly negative effect on children's language expression while the effects on language comprehension did not reach the significance level (p=0.085). Children's development at 12 months was related to psychosocial stimulation at home, nutritional status, education of parents, socioeconomic status, and care-giving practices of mothers at six weeks of age. Only a few mothers experienced each specific morbidity, and with the exception of anaemia, the sample-size was insufficient to make a conclusion regarding each specific morbidity. Further research with a sufficient sample-size of individual morbidities is required to determine the association of postpartum maternal morbidities with children's development.

Organizational and operational capabilities of specialist centres for children with psychomotor disability in Abidjan.

OBJECTIVE: To describe the organizational and operational capabilities of specialized centres for children with psychomotor disability in Abidjan, Republic of Côte d'Ivoire. MATERIALS AND METHODS: This descriptive study was carried out from February to May, 2006 at the various specialized centres for children with psychomotor disability that exist in the district of Abidjan. The procedure comprised a clinical description of the disabled children admitted to these centres and an assessment of the centres' organization and operational capabilities. RESULTS AND COMMENTS: Six specialist centres for children with psychomotor disability were identified, namely the Infant Guidance Centre, the Awakening and Stimulation Centre for disabled Children, the "Sainte-Magdeleine" Centre, the Medical and Training Institute, the "Page Blanche" institute and the "Colombes Notre Dame de la Paix" Centre. Among the children, 97.15% were day patients, 66.37% were mentally challenged, 30.96% had psychomotor impairment and 2.66% had motor impairments. The level of organization varied but the centres nevertheless had operational administrative, medical and paramedical staff, despite the absence of certain specialties. However, the lack of personnel, equipment and infrastructure is hindering the delivery of adequate services to the children. CONCLUSION: In Abidjan District, reception centres for children with psychomotor impairments are essentially privately run. Organizational and operational performances were suboptimal, with a low carer-to-patient ratio. Reinforcement of the centres' operational capabilities appears to be necessary.

Socioeconomic status, anthropometric status, and psychomotor development of Kenyan children from resource-limited settings: a path-analytic study.

BACKGROUND: Sub-optimal physical growth has been suggested as a key pathway between the effect of environmental risk and developmental outcome. AIM: To determine if anthropometric status mediates the relation between socioeconomic status and psychomotor development of young children in resource-limited settings. STUDY DESIGN: A cross-sectional study design was used. SUBJECTS: A total of 204 (105 girls) children from two resource-limited communities in the Coast Province, Kenya. The mean age of these children was 29 months (SD = 3.43; range: 24-35 months). OUTCOME MEASURE: Psychomotor functioning was assessed using a locally developed and validated measure, the Kilifi Developmental Inventory. RESULTS: A significant association was found between anthropometric status (as measured by weight-for-age, height-for-age, mid-upper arm circumference, and head circumference) and psychomotor functioning and also between socioeconomic status and anthropometric status; no direct effects were found between socioeconomic status and developmental outcome. The models showed that weight, height and to a lesser extent mid-upper arm circumference mediate the relation between socioeconomic status and developmental outcome, while head circumference did not show the same effect. CONCLUSION: Among children under 3 years living in poverty, anthropometric status shows a clear association with psychomotor development while socioeconomic status may only have an indirect association.

Quality and costs of community-based residential supports for people with mental retardation and challenging behavior.

A longitudinal matched-groups design was used to examine the quality and costs of community-based residential supports to people with mental retardation and challenging behavior. Two forms of provision were investigated: noncongregate settings, where the minority of residents had challenging behavior, and congregate settings, where the majority of residents had challenging behavior. Data were collected for 25 people in each setting. We collected information through interviewing service personnel in each type of setting on the costs of service provision, the nature of support provided, and the quality of life of residents. We also conducted observations in each setting. Results suggest that noncongregate residential supports may be more cost effective than congregate residential supports.

Clinically significant gastroesophageal reflux in the at-risk premature neonate: relation to cognitive scores, days in the NICU, and total hospital charges.

OBJECTIVE: The principal objective of this retrospective, cohort study was to determine if clinically significant gastroesophageal reflux (GER) would impair the long-term cognitive and motor development of preterm infants. An additional objective was to determine the effects of clinically significant GER on the length of hospital stay and total hospital charges in preterm infants. STUDY DESIGN: The design was a retrospective, cohort study of 66 preterm infants, followed in the Neonatal Developmental Follow-Up Clinic of The Children's Hospital in Greenville, SC. Thirty-three premature infants with clinically significant GER met the following study criteria: birth dates, 1988 through 1994; lack of gastrointestinal anatomic defects; and lack of acute neurologic injury (defined as no intraventricular hemorrhage greater than Papile's grade I, no periventricular leukomalacia, no seizures, and no history of birth asphyxia). Clinically significant GER was defined as GER associated with moderate to severe apnea (n=29) or GER associated with moderate to severe feeding intolerance (n=4). The study patients were matched as closely as possible with 33 control premature infants for sex (except when twins were used), ethnicity, social risk, gestational age, birth weight, and Apgar scores at 1 and 5 minutes. Social risk was categorized using Hack's Social Risk Scale. Important covariates included apnea, home monitoring, and nasal continuous positive airway pressure. RESULTS: Neurodevelopmental test scores from 7 months of age through 2 years of age did not show any significant differences between premature infants with clinically significant GER and premature infants with no evidence of clinically significant GER. Total hospital charges were statistically different for the clinically significant GER infants and the nonclinically significant GER infants (median $112,916 versus median $63,928, p=0.01). Total neonatal intensive care unit length of stay measures were statistically different between the two groups (median 53 days versus median 40.5 days, p=0.01). CONCLUSION: Even though clinically significant GER may pose a substantial medical risk in premature infants, the long-term cognitive consequences appear to be negligible. Nevertheless, those premature infants with clinically significant GER do consume significantly more hospital resources than matched controls. Early diagnosis and intervention may possibly lessen the impact of medical costs and reduce length of hospital stay.

The economic burden imposed by a residual case of eastern encephalitis.

To estimate the economic burden imposed by eastern encephalitis (EE), we identified a series of residents of eastern Massachusetts who had survived EE infection and enumerated any costs that could be attributed to their experience. The records of three people who suffered only a transient episode of disease were analyzed as well as those of three who suffered severe residual sequelae. Transiently affected subjects mainly required assistance for direct medical services; the average total cost per case was $21,000. Those who suffered persistent sequelae remained at home and seemed likely to live a normal span of years, but without gainful employment. Early in the course of their chronic illness, costs ranged as high as $0.4 million per year, but plateaued at about $0.1 million after three years. Hospital costs, which dominated early in the disease experience, approached $0.3 million per patient. Educational costs tended to replace hospital costs after two years as the dominant economic burden and totaled about $0.3 million per patient during the first six years. Total costs then averaged almost $0.8 million. By the time that these subjects will have reached 22 years of age, disease-related costs will have totaled about $1.5 million. Institutionalization will impose an additional lifetime cost of $1.0 million. Insecticidal interventions designed to avert outbreaks of human EE infection cost between $0.7 million and $1.4 million, depending on the extent of the treated region. The direct costs of an intervention are less than the $3 million imposed on one person suffering residual sequelae of EE.