Preterm Birth Causes, Consequences, and Prevention (2007) / Chapter Skim
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11 Neurodevelopmental, Health, and Family Outcomes for Infants Born Preterm
11 Neurodevelopmental, Health, and Family Outcomes for Infants Born Preterm
Pages 346-397
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From page 346... ...
The smallest and most immature infants have the highest risk of health problems and neurodevelopmental disabilities. Limited evidence of the impact of prematurity on families suggests that caring for a child born preterm has negative and positive effects that change over time, that these effects extend to adolescence and are 346
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From page 347... ...
In addition to infants born preterm, studies with samples of infants with birth weights less than 2,500 grams include full-term infants who are small for gestational age. When this literature is examined, it is also well to keep in mind that preterm delivery is not a disease with a fixed set of outcomes.
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From page 348... ...
Relatively few studies of the outcomes for infants born preterm provide comparison groups, and those that do have almost uniformly selected healthy full-term infants or infants with birth weights above 2,500 grams. Some have used siblings or classmates as comparisons.
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From page 349... ...
It highlighted the need for neurodevelopmental follow-up of populations born preterm, especially as the emergence of neonatal intensive care and high-risk obstetric care dramatically reduced gestational age-specific mortality rates but not preterm birth rates (see Chapters 1, 2, and 10)
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From page 350... ...
In their seventh report of CP in Sweden, Hagberg and associates (1996) reported an almost stepwise increase in the prevalence of CP with gestational age: 1.4 per 1,000 live births for children born at more than 36 weeks gestation, 8 per 1,000 live births for children born between 32 and 36 weeks gestation, 54 per 1,000 live births for children born between 28 and 31 weeks gestation, and 80 per 1,000 live births for children born at less than 28 weeks of gestation.
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From page 351... ...
. A comprehensive British study of preterm infants born in 1995 with gestational ages of less than 26 weeks diagnosed CP in 20 percent of the survivors at 6 years of age (Marlow et al., 2005)
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From page 352... ...
Palsy (%) Hintz et al., 2005a 1996–1999 1.8 87 467 <25 21 1993–1996 77 360 <25 23 Vohr et al., 2005a 1997–1998 1.8 84 910 <27 18 82 512 27–32 11 1995–1996 1.8 84 716 <27 19 81 538 27–32 11 1993–1994 1.8 74 665 <27 20 70 444 27–32 12 Mikkola et al., 2005 1996–1997 5 95 103 <27 19 Tommiska et al., 2003 1996–1997 1.5–2 100 5 22–23 20 18 24 11 34 25 12 47 26 11 Wood et al., 2000 1995 2.5 92 283 <26 18 Emsley et al., 1998 1990–1994 2.2–6.1 100 40 23–25 18 Piecuch et al., 1997b 1990–1994 >1 95 18 24 11 30 25 20 38 26 11 94 24–26 13 Jacobs et al., 2000 1990–1994 1.5–2 90 274 23–26 15 Doyle, 2001 1991–1992 5 98 221 23–27 11 1990–1992 3 98 362 23–24 14 Finnstrom et al., 1998a 25–26 10 >26 3 Lefebvre et al., 1996 1991–1992 1.5 85 9 24 11 24 25 25 40 26 27 72 27 10 72 28 17 217 24–28 17 aBirth weight less than 1,000 grams.
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From page 353... ...
Although less than 10 percent of births are preterm, approximately 40 to 50 percent of children with CP are born preterm. Although children born preterm are vulnerable to all types of CP, the most common type is spastic diplegia (Hack et al., 2000; Hagberg et al., 1996; Wood et al., 2000)
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From page 354... ...
. In a study of 5-year-olds born between 1996 and 1997 with birth weights of less than 1,000 grams, 51 percent had coordination problems, 18 to 20 percent had abnormal reflexes or abnormal posture, and 17 percent had exceptional involuntary movements (Mikkola et al., 2005)
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From page 355... ...
. This issue is more important arithmetically the younger the infant is and the lower the gestational age at birth was.
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From page 356... ...
On the basis of data for preterm children born in the late 1980s and 1990s, survivors born preterm with the lowest gestational ages and birth weights have the highest risk of mental retardation and borderline intelligence (Tables 11-2 and 11-3)
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From page 357... ...
. A 2002 meta-analysis of 16 case-control studies of children aged 5 years old or older and born from 1975 to 1988 noted significantly lower cognitive scores for 1,556 children born preterm compared with those for 1,720 controls born full term, with a weighted mean difference of 10.9 (95% CI 9.2–12.5)
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From page 358... ...
358 PRETERM BIRTH TABLE 11-2 Mean IQ Scores in Children Born Preterm and Full Term Year(s) Number Study of Birth Age (yr)
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359 NEURODEVELOPMENTAL, HEALTH, AND FAMILY OUTCOMES Mean IQ Score (Standard Deviation) Rate of Gestational Birth Preterm Full-Term Follow-up (%)
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360 PRETERM BIRTH TABLE 11-3 Proportion of Survivors of Preterm Birth With and Without Cognitive Impairment Year(s) Rate of Study of Birth Age (yr)
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From page 361... ...
361 NEURODEVELOPMENTAL, HEALTH, AND FAMILY OUTCOMES Percentage of Subjects with Scores: 2 SDs 1–2 SDs Number Gestational Birth below below of Subjects Age (wk) Weight (g)
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From page 362... ...
Adolescents and young adults who were born preterm continue to demonstrate a cognitive disadvantage compared with those who were born fullterm. When young adults who were born with birth weights of less than 1,000 grams were tested at a mean age of 18 years, they were found to have lower verbal, performance, and full-scale IQ scores than fullterm controls: 93 and 106, 97 and 109, and 94 and 108, respectively (p < 0.0001)
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From page 363... ...
Among 8- to 10-year-old children who were born preterm with birth weights of less than 800 or 1,000 grams, 13 to 33 percent repeated a grade, 15 to 47 percent required some special education support, and 2 to 20 percent were in special education placements (Buck et al., 2000; Gross et al., 2001; Whitfield et al., 1997)
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From page 364... ...
Ample evidence suggests that many more children born preterm have specific learning disabilities than children of normal birth weight born fullterm. By school age, despite normal intelligence, children born with birth weights of less than 1,000 or 800 grams have a 3- to 10-fold increased risk of problems with reading, writing, spelling, or mathematics compared with the risk for their peers who had been born fullterm (Aylward, 2002a; Grunau et al., 2002; Hall et al., 1995; O'Callaghan et al., 1996; Ornstein et
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From page 365... ...
. The proportion of children born preterm who experience academic difficulties increases with age as the complexity of the schoolwork increases and efficiency becomes an issue in the higher grade levels (Aylward, 2002a)
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From page 366... ...
is one of the most common visual sequelae, and its incidence increases with the severity of ROP and with decreasing gestational age. Myopia occurs in 20 to 22 percent of children born with birth weights of less than 1,251 or 1,751 grams, and 4.6 percent have a high degree of myopia (i.e., ≥ 5 diopters)
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From page 367... ...
TABLE 11-4 Sensory Impairments in Children Born Preterm Percentage with Severe Impairment Year No. of Gestational Birth Study of Birth Subjects Age (yr)
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From page 368... ...
. Although most retinal tears or detachments occur in those with severe ROP, some children born preterm had mild or no ROP but a high degree of myopia (Kaiser et al., 2001)
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From page 369... ...
. Hearing Impairment Children born preterm have a higher incidence of hearing loss than the general population.
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From page 370... ...
Symptoms suggestive of ADHD occur two to six times more frequently in children born preterm with birth weights of less than 1,000 grams, less than 1,500 grams, and less than 2,000 grams than in controls born fullterm (9 to 15 percent diagnosed with ADHD compared with 2 percent of controls born fullterm) (Aylward, 2002a; Bhutta et al., 2002; Breslau, 1995; Levy, 1994; Pharoah et al., 1994; Saigal et al., 2001; Stjernqvist and Svenningsen, 1995; Szatmari et al., 1990; Taylor et al., 1998)
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From page 371... ...
. Conduct disorders are more common in children born preterm, but so are traits such as shyness, unassertiveness, withdrawn behavior, and social skill deficits (Bhutta et al., 2002; Grunau et al., 2004; Sommerfelt et al., 1996)
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From page 372... ...
of the children with birth weights of less than 1,000 grams and 40 percent with birth weights of less than 750 grams had no disabilities. Although a relatively small proportion of children born preterm have multiple disabilities, this group of children faces significant challenges with respect to mobility, academics, and the transition toward independence.
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From page 373... ...
For children born preterm in the 1990s, 28 percent born at 27 to 32 weeks gestation, 13 to 25 percent weighing less than 1,000 grams at birth, 45 percent born at less than 27 weeks of gestation, 58 percent born at 24 weeks of gestation, and 61 percent born at less than 24 weeks of gestation had neurosensory or neurodevelopmental impairment, whereas 1 percent of controls born fullterm had such impairments (Hansen and Greisen, 2004; Hintz et al., 2005; Saigal et al., 2000c; Vohr et al., 2005; Wilson-Costello et al., 2005)
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From page 374... ...
. Functional Outcomes Authors of studies of the outcomes for children born preterm have struggled with how to convey the full range of outcomes.
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From page 375... ...
Several studies have reported on the functional abilities of 5- to 6-yearold children born preterm. In a study of 149 children born at less than 28 weeks gestation who were in kindergarten, 95 percent could walk and perform basic self-care skills and were continent during the daytime (Msall et al., 1992)
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From page 376... ...
Other investigators have found lower rates of graduation from high school among young adults born weighing less than 1,000 or 1,500 grams compared with the rates for controls with normal birth weights (Cooke et al., 2004; Lefebvre et al., 2005)
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From page 377... ...
Subanalyses, however, revealed that more participants born with extremely low birth weights reported that they were neither in school nor employed, although these differences disappeared when those with disabilities were excluded. These results suggest that individuals born preterm can make a successful transition into adulthood.
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From page 378... ...
. Although prenatal and intrapartum factors can adversely influence the outcomes for infants born preterm, many neonatal factors are stronger predictors (Allen, 2005b)
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From page 379... ...
and deep nuclear structures, in infants and children born preterm as compared with fullterm control children (Peterson et al., 2000; Peterson, 2003)
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From page 380... ...
. There is some evidence that maternal mental health influences the outcomes for children born preterm.
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From page 381... ...
. Growth Besides acute and chronic conditions, infants born preterm or with birth weights below 2,500 grams also experience poorer growth.
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From page 382... ...
found that adolescents with birth weights less than 1,000 grams demonstrated patterns of catch-up growth between age 8 and adolescence. Studies on the ultimate growth attainment or growth during the adolescent years and into early adulthood for individuals born preterm are only recently appearing in the literature.
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From page 383... ...
To date, there are limited studies on Quality of Life (QL) in children, and even fewer in children born preterm.
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From page 384... ...
. The children with birth weights less than 1,000 grams had functional limitations in several attributes, and mean HRQL scores were significantly lower than in controls (Saigal et al., 1994b)
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From page 385... ...
intraventricular hemorrhage. Recently, several studies have reported the HRQL in young adults born preterm.
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From page 386... ...
In addition, most investigators did not differentiate low birth weight from small for gestational age or prematurity, and did not measure postnatal growth. Thus, birth weight and early growth were used as surrogates for overall somatic growth, with
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From page 387... ...
have demonstrated that 4- to 10year- olds born preterm have metabolic abnormalities similar to those observed in infants born fullterm but small for gestational age and that these occur irrespective of whether the preterm infants are small or appropriate for gestational age. In fact, there did not seem to be an additive effect on reduced sensitivity from being born both preterm and small for gestational age.
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From page 388... ...
have recently shown that by the time that infants born preterm reached their term age, they had a highly significant decrease in subcutaneous adipose tissue and significantly increased levels of intra-abdominal adipose tissue. They caution that preterm infants may be at risk of metabolic complications later in life through this increased and aberrant adiposity.
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From page 389... ...
IMPACT OF PRETERM BIRTH ON FAMILIES Families caring for a child born preterm face long-term and multilayered challenges. The limited research on this topic suggests that this impact is largely negative (Beckman and Pokorni, 1988; Cronin et al., 1995; Davis et al., 2003; Eisengart et al., 2003; Lee et al., 1991; Macey et al., 1987; McCain, 1990; McCormick et al., 1986; Singer et al., 1999; Stjernqvist and Svenningsen, 1995; Taylor et al., 2001; Veddovi et al., 2001)
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From page 390... ...
. Longitudinal studies of children born preterm and with low birth weights in the first 2 to 3 years of life suggest that the levels of maternal depression and psychological distress (Singer et al., 1999)
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From page 391... ...
. When the neonate born preterm was 3 months of age, it was found that informal support, the number of siblings, and the family's socioeconomic condition were the most important factors; at 6 months of age, gestational age at birth, home environment, caregiving demands, and the number of parents in the home were the most important;
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From page 392... ...
Similarly, the child's health and functional health status were assessed on the basis of the presence of serious health conditions in one study, whereas other studies formally assessed functional health status by the use of validated measures. Future studies could advance knowledge in this area by developing a measure that would capture the particular health and functional health challenges that these families and the children born preterm face.
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From page 393... ...
Researchers should be encouraged to focus on prematurity by gestational age in addition to birth weight, so that the variations in the impacts on families can be ascertained by gestational age. Finally, studies of the impacts of an infant born preterm on families during the child's infancy should assess outcomes beyond maternal depressive symptoms in the postpartum period.
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From page 394... ...
Avon Premature Infant Project The United Kingdom Avon Premature Infant Project was a randomized controlled trial in which the parents of 284 infants born at less than 33 weeks gestation received a home-based developmental education program,
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From page 395... ...
NEILS is focusing on, among other issues, the early intervention services that participating children and families receive and the outcomes that participating children and families experience. Because this study will also assess how outcomes relate to variations in child and family characteristics and the services that they received, it has particular relevance for infants born preterm and their families.
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From page 396... ...
Summary Although the short-term impact of early interventions has been well demonstrated, the findings of evaluations of the long-term impact of early interventions for preterm infants have been ambiguous. Long-term prenatal and perinatal cohort studies conducted before the introduction of neonatal intensive care concluded that social factors and the quality of the home environment can compensate for the disadvantages encountered perinatally and neonatally (Wolke, 1998)
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From page 397... ...
CONCLUSION There is a wide range of health and neurodevelopmental outcomes for infants born preterm, and many resources are required to provide the necessary medical, neurodevelopmental and educational support for the children and support for their families. More outcomes data are reported by birth weight categories than by gestational age categories, but until better measures of organ maturation are available, information regarding gestational age is necessary for medical decision making and parent counseling when a preterm delivery is anticipated.
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