Most very low birth weight subjects do well as adults.

AIM: To study health, quality of life, educational level and occupation in very low birth weight (VLBW) children in early adulthood and the relationship of the findings to neonatal risk factors and later handicap. METHODS: This is a prospective long-term follow-up study of a regional cohort of 20-year-old VLBW subjects (n = 77) of all surviving VLBW children (n = 86) and 69/86 term controls born in 1987-1988 in the south-east of Sweden. Postal questionnaires were used: 1. A study-specific form, 2. Medical Outcomes Study, Short Form (SF-36), 3. Sense of Coherence. RESULTS: VLBW subjects did not differ significantly from their controls in self-perceived health, use of tobacco, education, occupation and way of living, or scoring on SF-36 and Sense of Coherence. Sixteen had cerebral palsy, attention deficit hyperactivity disorder or isolated mental retardation, and these subjects differed significantly from controls on SF-36 in physical functioning and physical health score, but not on Sense of Coherence. VLBW subjects were significantly lighter and shorter than their controls. Extremely low birth weight (ELBW), bronchopulmonary dysplasia and intraventricular haemorrhage were significantly associated with poorer scores on physical function. CONCLUSION: The 20-year old VLBW subjects reported perceived health and managed transition to adulthood similar to controls. Handicapped subjects had poorer self-perceived physical function. ELBW and severe neonatal complications were associated with poorer self-perceived physical health.

Use of healthcare resources, family function, and socioeconomic support during the first four years after preterm birth.

OBJECTIVES: To assess the use of healthcare resources for preterm infants and to evaluate family function and socioeconomic support in a defined population from birth to 4 years of age. METHODS: In a prospective case-control study, 39 singleton preterm infants without prenatal abnormalities born during an 18 month period were studied together with their families. The population consisted of 19 very preterm infants (less than 32 weeks) and 20 randomised moderate preterm infants (32-35 weeks), and the control group comprised 39 full term infants. Contacts with medical services, child health services, and the social welfare system were registered, and family function and life events were studied. RESULTS: The preterm children were more often readmitted to hospital (odds ratio (OR) 6.6, 95% confidence interval (CI) 2.0 to 22.1) and had more outpatient attendances (OR 5.6, 95% CI 2.1 to 15.0) during their first year of life. Mothers in the preterm group more often used temporary parental allowance than the control mothers (p < 0.001). The number of contacts with the child health services and the social welfare system did not differ significantly from the controls. Neither was there any significant difference with regard to family function or life events at 4 years of age. CONCLUSIONS: A large proportion of the premature children used specialist care during the first years of life. However, the families of the preterm infants were socially well adapted up to four years after birth compared with the control families.

Assessment of behaviour on the Brazelton scale in healthy preterm infants from 32 conceptional weeks until full-term age.

20 healthy preterm infants were assessed weekly by the Brazelton Neonatal Behavioural Assessment Scale from 1-2 weeks after birth until they reached their expected date of birth. The gestational age of the infants ranged from 28 to 34 weeks. Although the full scale could not be used before 36 conceptional weeks, obvious progress in development was found for most items of the scale. In particular there was improvement in orienting responses and in motor performance during the observation period. At full-term age comparisons were made with a group of normal-term infants (n = 80). All premature infants underwent standard neonatal neurological examination at full term, and tests of neurological function and psychomotor development up to the age of 18 months.

Correlation between neurological examination and behavioural assessment of the newborn infant.

A modified Prechtl neurological examination and the Brazelton Neonatal Behavioural Assessment Scale (BNBAS) were used on days 1 and 5 in 78 healthy newborn infants. Correlations between variables in the neurological examination and the behavioural items and subscales in the BNBAS were calculated. Especially the total neurological score and optimality score were significantly correlated to motor performance (days 1 and 5) and to orienting responses to animate and inanimate stimuli (day 1) in the BNBAS. The neurological variables showed poor or no correlation to the habituation items and to certain items concerned with changes of behavioural state in the BNBAS.

An 18-month follow-up study of growth-retarded neonates. Relation to biochemical tests of placental function in late pregnancy and neurobehavioural condition in the newborn period.

Serial estimations of maternal urinary oestriol, serum cystine aminopeptidase (S-CAP), and human chorionic somatomammotrophin (S-HCS) were studied prospectively in 29 pregnancies complicated by intrauterine growth retardation. The newborn growth-retarded infants were examined by neurological and behavioural techniques. Growth variables and neurological and developmental findings were compared with those in 18 healthy controls at 5, 10 and 18 months of age. The growth-retarded infants caught up with regard to body size from 5 months of age, although the severely retarded infants (birth weight less than or equal to -2 SD) differed from the controls with regard to weight and head circumference at 18 months of age. Abnormal maternal oestriol excretions were negatively correlated to weight and length during the follow-up period. Infants who had been severely growth-retarded at birth were neurologically below optimal level at 10 months of age, compared to the controls. There were no significant differences between the growth-retarded infants and the controls with regard to psychomotor development, as assessed by a screening test and by Griffiths' method. Significant correlations were found between abnormal biochemical placental tests (especially urinary oestriol and S-CAP) and psychomotor development. Significant correlations also appeared between neonatal orientation and motor behaviour and some Griffiths' scales at 18 months of age. No relationship was found between the neurological condition in the neonatal period and the neurological findings and development at follow-up.

Neurology and behaviour of growth-retarded neonates. Relation to biochemical placental function tests in late pregnancy.

Serial estimations of maternal urinary oestriol, serum cystine aminopeptidase (S-CAP), and human chorionic somatomammotrophin (S-HCS) were done in a prospective study on 29 pregnancies in which intrauterine growth retardation was diagnosed in the third trimester by the gravidogram method and/or serial ultrasound measurements of the fetal biparietal diameter. The series was divided into 2 growth-retarded groups: (i) severe growth retardation with birth weight less than -2 SD from the mean for gestational age (N = 14); (ii) moderate growth retardation with birth weight between -1 and -2 SD from the mean for gestational age (N = 15). These were compared with a control group of 18 normal pregnancies and infants. A modified Prechtl neurological examination and the Brazelton Neonatal Behavioural Assessment Scale (NBAS) were done in the neonatal period at full-term age. Both categories of growth-retarded infants showed lower muscle tonus than the controls. The severely growth-retarded infants showed fewer optimal items in the neurological examination; they also showed poorer capacity for orientation to external stimuli, inferior motor function, and less physiological stability in NBAS than the controls. The abnormal biochemical placental tests were significantly correlated to low Apgar scores (urinary oestriol), to low excitability (S-CAP) and to poor motor function (S-HCS). The neurological and behavioural condition of the neonate seemed to be more closely associated to the extent of growth retardation than to the occurrence of abnormal biochemical placental tests.

Influence of elective cesarean section and breech delivery on neonatal neurological condition.

Fifty-three infants born after elective cesarean section (CS), and 28 infants born vaginally in breech presentation were compared with 45 full-term controls. A quantitative neurological assessment consisting of 31 items was performed on days 1, 2 and 5 after birth. A tonus score, an excitability score and the number of optimal responses were calculated. A follow-up examination was done at 6 months of age, with a standardized neurological and developmental examination. The results showed that infants born after elective CS in both vertex and breech presentation had significantly reduced number of optimal responses during the first five days after delivery, compared to controls. They were more hypotonic and less excitable than the control infants during the first 2 days. There were no significant differences in neurological results between infants born after CS with general or epidural anaesthesia. The infants born in vaginal breech presentation showed no differences neurologically as compared to the controls on the first day. On days 2 and 5, however, they were less excitable and showed a reduced number of optimal responses. There were few differences in neurological condition between the infants born after elective CS and the infants born vaginally in breech presentation. Growth, psychomotor development and neurological status at 6 months did not differ significantly between the three groups. Our findings indicate that infants born after elective CS and vaginal breech presentation have a delayed neurological adaptation during their first days of life. These differences did not affect the physical well-being of the infants, which showed normal growth, neurology and development at the follow-up at 6 months of age.

Delayed neurological adaptation in infants delivered by elective cesarean section and the relation to catecholamine levels.

We have studied the effect of mode of delivery and catecholamine (CA) surge at birth on neurobehaviour 1, 2 and 5 days after birth. Fifteen full-term infants were delivered by elective cesarean section (CS) and 15 full-term control infants were born vaginally. Infants born after elective CS were less excitable and had significantly reduced number of optimal responses during the first 2 days after delivery, compared to the controls. On the 5th day no significant neurological differences were found between the groups. Adrenaline and noradrenaline (NA) in umbilical arterial plasma were analysed in all infants. The mean values of NA were lower in the CS infants as compared to the vaginally delivered infants. Statistically significant correlations were found between low CA levels and poor muscle tone and/or lower grade of excitability in the CS infants. These results suggest that the high CA surge at birth might be of importance for the neurological adaptation after birth.

Very-low-birth-weight children at school age: academic achievement, behavior and self-esteem and relation to risk factors.

OBJECTIVE: To investigate school performance, behavior and self-esteem of children with very low birth weight (VLBW). METHODS: All children with birth weight below 1501 g (VLBW) and normal birth weight controls, born in the south-east region of Sweden during a 15-month period in 1987-88, were enrolled in a prospective follow-up study. At the age of 9 years, 81% and 82%, respectively, were re-examined regarding growth, neurofunctional classification, academic achievement tests, need for special education and behavioral problems. At 12 years, 89% and 76%, respectively, were re-examined regarding growth, neurofunctional classification, visual acuity and self-esteem. RESULTS: VLBW children were shorter and lighter, and differed from the controls with regard to neurological functional classification. They produced poorer results in most academic achievement tests. When the comparison was restricted to children with normal intelligence, almost all the differences in other academic achievements disappeared. VLBW children had more reading difficulties but were less often than expected defined as dyslexics compared to control children. We did not find any major disparity in visual acuity and self-esteem between the groups. Low Apgar scores, intracranial hemorrhage and the need for mechanical ventilation neonatally were associated with poorer results in most outcome measures. Neurofunctional assessments in early childhood were associated with most outcome measures. The mother's education was related to delayed reading skills and need for special education. CONCLUSIONS: Although VLBW children performed less well in most academic achievement tests and on some behavioral subscales, those who had a normal intellectual capacity did not differ in any important aspects from the controls.

[Good prognosis for very low birth weight infants]. / God prognos för barn med mycket låg födelsevikt.

A population-based multicentre study, comprising all very low birthweight (VLBW; < or = 1,500 g) infants born alive in the south-east region of Sweden during a 15-month period, was performed in the late 1980s. Among the VLBW infants there were 107 lifebirths (a rate of 0.72%), 86 (80.4%) neonatal survivors and no late deaths. Twenty (18.4%) had intracranial complications, two (2.3%) retinopathy of prematurity, grade 3, and six (5.6%) bronchopulmonary dysplasia. At follow-up at 18 months of uncorrected age, the VLBW infants were still lighter in weight and of shorter stature than control group infants. Of the five (5.8%) of the surviving VLBW infants who had significant neurological disorder at 18 months of age, all had weighed less than 800 g at birth, and had manifested neurological symptoms at 6 months of age. The hospitalisation rate during the first 18 months of life was greater in the VLBW than the control group.

[School maladjustment common among children with very low birth weight Special attention and support are required during school start]. / Skolsvårigheter vanliga hos barn med mycket låg födelsevikt. Extra uppmärksamhet och stöd behövs vid skolstart.

Children of very low birth weight (VLBW), defined as less than 1500 g, and normal birth weight controls (NBW) were enrolled in a long-term follow-up study. Five of 86 surviving VLBW children had a neurological handicap. Seventy VLBW children and 72 NBW children were re-examined at the age of nine, which entailed a neurological examination, a non-verbal intelligence test and a test for reading ability, mathematical skills and vocabulary. Their behavior was rated regarding hyperactivity, social behavior and fine and motor skills. The two groups differed with regard to the neurological examination and the tests, with poorer results shown for the low birth weight group. The VLBW children were also more hyperactive and scored lower on fine motor skills. Considering only those who scored normally as regards non-verbal intelligence (54% of VLBW children and 88% of controls), practically all differences disappeared.

The prognostic significance of antenatal diagnosis of fetal growth retardation.

Intrauterine growth retardation is associated with high risk of perinatal asphyxia. The neonatal mortality rate of small-for-gestational-age (SGA) infants (birthweight < or = 2 SD) in Sweden decreased from 5.6% in 1973 to 2.0% in 1987. During the same period, the number SGA infants with postnatal asphyxia (5 min Apgar score < 7) decreased from 10% to 5%. Based on antenatal diagnosis of fetal growth retardation, an optimal time of delivery reduces the risk of major neurological and developmental sequelae of the individual infant.

Neurology and behaviour of newborn infants delivered by vacuum extraction on maternal indication.

23 full-term neonates delivered by vacuum extraction (VE) on maternal indication (primary or secondary uterine inertia) but with no sign of fetal asphyxia and a control group of 16 infants were studied. The infants were examined on the 1st and 5th days after birth with the Brazelton Neonatal Behavioural Assessment Scale and by a standardized neurological examination. On day 1 the VE-infants showed lower visual and auditory responsiveness in the behavioural assessment, and fewer optimal responses in the neurological examination than did the controls. Obstetrical factors such as abnormal presentation, long duration of the second stage of labour, and long duration of VE (greater than or equal to 15 minutes) may explain the differences. The differences between the groups had largely disappeared by day 5.

Studies on the Brazelton neonatal behavioural assessment scale.

The Brazelton neonatal behavioural assessment scale was applied in 120 healthy full-time newborn infants. Interobserver reliability on day 5 (n = 20), test-retest reliability on day 4-5 (n = 20), and correlations between examinations on day 1 and day 5 (n = 80) were studied with regard to individual and grouped items (subscale) in the test. The over-all interobserver reliability generally seemed to be satisfactory, but low estimates of test-retest reliability were obtained for many items. Items assessing orientation capacity and regulation of state showed better test-retest stability when the predominate states were identical on both occasions. Some subscales were significantly related to parity, sex, birthweight, and age in hours at examination.

Neurological adaptation of infants delivered by emergency or elective cesarean section.

The effects of intrapartal asphyxia on neonatal neurological condition have been studied in 17 full-term infants delivered by emergency cesarean section and in 30 full-term infants delivered by elective cesarean section used as controls. A neurological examination consisting of 31 items was performed on days 1, 2 and 5 after birth. A tonus score, an excitability score as well as the number of optimal responses were calculated. A follow-up examination was done at six months of age with a standardized neurological and developmental examination. The results showed that infants born after emergency cesarean section were significantly more hypotone the first two days after delivery than the infants in the elective cesarean section group. In regard to individual neurological items, significant differences were found between the emergency and elective cesarean section in reaction to sound, rooting, patellar, Moro and stepping reflexes with weaker reactions in the elective cesarean section group. Growth, psychomotor development and neurological status at six months did not differ significantly between the groups. Our findings indicate that full-term infants born after emergency cesarean section due to mild intrapartal asphyxia have a delayed neurological adaptation as expressed by poor muscular tonus during their first days of life compared with infants born after elective cesarean section.

Spontaneous labor and elective induction--a prospective randomized study. I. Effects on mother and fetus.

In a prospective randomized study spontaneous and oxytocin induced labor "for convenience" have been compared with respect to uterine activity, duration of labor, the condition of the fetus and the newborn infant. The study consists of 84 normal patients, of whom 43 were induced at full term by amniotomy and oxytocin infusion using the Cardiff Infusion System Mark II; 41 patients served as controls. No difference in maternal age, number of previous pregnancies and pelvic score one week before the day of delivery were found between the groups. The following parameters were calculated: duration of labor, uterine activity, amount of bleeding in the third stage of labor, number of early and late decelerations as well as number of episodes of bradycardia in the CTG-recordings, birth weight, Apgar score one and five minutes post-delivery and blood gases in mother and child 60 seconds after delivery. No significant differences between the two groups were found. It is concluded that there are no increased risks to mother or fetus compared to normal labor provided that there is cephalic presentation and normal pregnancy, careful selection with respect to the length of pregnancy and the condition of the cervix and that the Cardiff infusion system is used with intrauterine pressure recording and continuous fetal heart monitoring.

Spontaneous labour and elective induction--a prospective randomized study. Behavioural assessment and neurological examination in the newborn period.

The effect of induction of labour on the foetus and the newborn was investigated in a prospective randomized study. 41 neonates were studied after induction at full term by amniotomy and intravenous oxytocin infusion. The infusion rate was regulated by the intraamniotic pressure using the Cardiff infusion pump system. 39 neonates served as controls where the labour started spontaneously followed by amniotomy. In both groups foetal heart rate monitoring intraamniotic pressure recordings were performed. There were no differences in Apgar score and pH in cord blood between the groups. The newborns were evaluated the first and the fifth day of life with the Brazelton Neonatal Behavioral Assessment Scale and with a modified Prechtl neurological examination. There were no differences in behaviour and neurological state between the two groups. However, within the groups there were significant differences between the first and the fifth day concerning both neonatal behaviour and neurological state.

Neurological condition of large-for-gestational-age infants during the newborn period.

Thirty-two large-for-gestational-age (LGA) infants and 46 appropriate-for-gestational-age (AGA) infants used as controls, were investigated. LGA and AGA infants did not differ regarding instrumental deliveries or asphyxia. The infants were examined on the 1st and 5th days after birth with a standardized neurological assessment. The LGA infants showed a significantly delayed neurological adaptation with fewer optimal responses on day one as compared to the AGA infants. These differences were not observed on day five. There were no neurological differences between prenatally and postnatally detected LGA infants. No significant differences were observed regarding parity on maternal complications, neonatal course, and neurological scores of the LGA infants.