0
We're unable to sign you in at this time. Please try again in a few minutes.
Retry
We were able to sign you in, but your subscription(s) could not be found. Please try again in a few minutes.
Retry
There may be a problem with your account. Please contact the AMA Service Center to resolve this issue.
Contact the AMA Service Center:
Telephone: 1 (800) 262-2350 or 1 (312) 670-7827  *   Email: subscriptions@jamanetwork.com
Error Message ......
Article |

Neurodevelopment and Predictors of Outcomes of Children With Birth Weights of Less Than 1000 g:  1992-1995 FREE

Maureen Hack, MB, ChB; Deanne Wilson-Costello, MD; Harriet Friedman, MA; Gerry H. Taylor, PhD; Mark Schluchter, PhD; Avroy A. Fanaroff, MB, BCh
[+] Author Affiliations

From the Department of Pediatrics, School of Medicine, Case Western Reserve University, Cleveland, Ohio.


Arch Pediatr Adolesc Med. 2000;154(7):725-731. doi:10.1001/archpedi.154.7.725.
Text Size: A A A
Published online

Objective  To examine the neurosensory and cognitive status of extremely low-birth-weight (ELBW; <1000 g) children born from January 1, 1992, through December 31, 1995, and to identify the significant predictors of outcome.

Design  An inception cohort of ELBW infants admitted to the neonatal intensive care unit (NICU) and observed to 20 months' corrected age.

Setting  A tertiary level urban NICU and follow-up clinic at a university hospital.

Population  Of 333 ELBW infants without major congenital malformations admitted to the NICU, 241 (72%) survived to 20 months' corrected age. We studied 221 children (92%) at a mean of 20 months' corrected age. The mean birth weight was 813 g; mean gestational age, 26.4 weeks.

Main Outcome Measures  Assessments of cognitive and neurosensory development.

Results  Major neurosensory abnormality was present in 54 children (24%), including 33 (15%) with cerebral palsy, 20 (9%) with deafness, and 2 (1%) with blindness. The mean (± SD) Bayley Mental Developmental Index (MDI) score was 74.7 ± 17. Ninety-two children (42%) had a subnormal MDI score (<70). Neurodevelopmental impairment (neurosensory abnormality and/or MDI score <70) was present in 105 children (48%). Multiple stepwise logistic regression analysis that considered sex, social risk, birth weight, and neonatal risk factors revealed significant predictors of a subnormal MDI score to be male sex (odds ratio [OR], 2.73; 95% confidence interval [CI], 1.52-4.92), social risk (OR, 1.48; 95% CI, 1.09-2.00), and chronic lung disease (OR, 2.18; 95% CI, 1.20-3.94). Predictors of neurologic abnormality were a severely abnormal finding on cerebral ultrasound (OR, 8.09; 95% CI, 3.69-17.71) and chronic lung disease (OR, 2.46; 95% CI, 1.12-5.40); predictors of deafness were male sex (OR, 2.79; 95% CI, 1.02-7.62), sepsis (OR, 3.15; 95% CI, 1.05-9.48), and jaundice (maximal bilirubin level, >171 µmol/L [>10 mg/dL]) (OR, 4.80; 95% CI, 1.46-15.73).

Conclusion  There is an urgent need for research into the etiology and prevention of neonatal morbidity.

Figures in this Article

PERINATAL TREATMENT of extremely low-birth-weight (ELBW; <1000 g) children in the 1990s has, in addition to surfactant therapy, been associated with new ventilator strategies and an increased use of pharmacological agents, including antenatal and postnatal steroids and indomethacin.13 Previous reports from our perinatal center studied the worsening early childhood outcomes of children with birth weights of less than 750 g born during 1993 through 1995, compared with previous years.4,5 With the exception of the National Institute of Child Health and Human Development (NICHD) Neonatal Network multicenter study of children born during 1993 through 1994,6 the most recent reports of the neurologic and developmental status of children with birth weights of less than 1000 g pertain to children born during 1990 through 1992.712

Because of the paucity of information on the outcomes of surviving children with birth weights of less than 1000 g born since 1992, and to have sufficient numbers of children to identify predictors of outcome, we sought to examine the early childhood cognitive and neurosensory status of all the children with birth weights of less than 1000 g treated at our perinatal center from January 1, 1992, through December 31, 1995. We furthermore sought to identify the significant correlates of outcome in this cohort.

Three hundred thirty-three ELBW infants without major congenital malformations were admitted to the neonatal intensive care unit at Rainbow Babies and Childrens Hospital, University Hospitals of Cleveland, Cleveland, Ohio, during the 4-year study period.

Two hundred forty-one children (72%) survived to 20 months' corrected age, of whom 221 (92%) underwent complete neurodevelopmental assessments at that time. Of the 20 children not included in the study population, 13 were unavailable for follow-up and 7 were not able to undergo testing (3 had neurosensory abnormalities, and 4 displayed severe behavioral difficulties and/or lack of cooperation).

A description of the maternal demographic risk factors and infant birth data is presented in Table 1. Demographic data included maternal age, race, marital status, and a composite Social Risk Score that includes marital status (married, 0; single, 1), race (white, 0; black, 1), and education (high school, 0; less than high school, 1).14 Major neonatal complications and therapies during the initial neonatal hospitalization are presented in Table 2. Chronic lung disease was defined as an oxygen dependence at 36 weeks' corrected age (postmenstrual plus postnatal age)15; episodes of sepsis (blood culture positive for sepsis plus clinical signs of sepsis); meningitis (spinal fluid culture positive for meningitis); necrotizing enterocolitis (according to Bell et al16); jaundice (maximum bilirubin level >171 µmol/L [>10 mg/dL]); and the most severe abnormal finding on cranial ultrasounds performed serially during the hospital stay (grade III or IV hemorrhage), periventricular leukomalacia (PVL), or persistent ventricular dilation at the time of discharge home.17 Apnea was defined as the need for theophylline or assisted ventilation for this condition.

Table Graphic Jump LocationTable 1. Maternal Demographic Risk Factors and Infant Birth Data*
Table Graphic Jump LocationTable 2. Neonatal Risk Factors and Therapies*

At 20 months' corrected age, 24 children (11%) were in foster care, 2 (1%) remained in the chronic care facility, and the remaining 195 (88%) lived at their parent's home. A physical and neurologic examination and the revised Bayley Scales of Infant Development (BSID II) were administered at this time (mean±SD corrected age, 19.7 ± 2 months18,19). Major neurologic abnormalities included cerebral palsy (spastic diplegia, hemiplegia, hemidiplegia [ie, triplegia] or quadriplegia), hypertonia, hypotonia, and shunt-dependent hydrocephalus without other neurologic abnormality. Hypotonia and hypertonia were included in the category of major neurologic abnormality, as these conditions are considered by some to represent a variant of cerebral palsy. Shunt-dependent hydrocephalus without neurologic abnormality was also considered an impairment.20 Sensory abnormality included unilateral or bilateral blindness or deafness.

There were no significant differences in birth data or neonatal risk factors between the 221 ELBW children followed up to 20 months' corrected age and the 20 children not undergoing testing; however, the latter group was at higher social risk (P=.04). Informed consent was obtained from the parents of the study children.

At 20 months' corrected age, 24 children (11%) were in foster care, 2 (1%) remained in the chronic care facility, and the remaining 195 (88%) lived at their parent's home. A physical and neurologic examination and the revised Bayley Scales of Infant Development (BSID II) were administered at this time (mean±SD corrected age, 19.7 ± 2 months18,19). Major neurologic abnormalities included cerebral palsy (spastic diplegia, hemiplegia, hemidiplegia [ie, triplegia] or quadriplegia), hypertonia, hypotonia, and shunt-dependent hydrocephalus without other neurologic abnormality. Hypotonia and hypertonia were included in the category of major neurologic abnormality, as these conditions are considered by some to represent a variant of cerebral palsy. Shunt-dependent hydrocephalus without neurologic abnormality was also considered an impairment.20 Sensory abnormality included unilateral or bilateral blindness or deafness.

There were no significant differences in birth data or neonatal risk factors between the 221 ELBW children followed up to 20 months' corrected age and the 20 children not undergoing testing; however, the latter group was at higher social risk (P=.04). Informed consent was obtained from the parents of the study children.

The t test was used to compare continuous measures and the χ2 test or Fisher exact test to compare categorical data. Outcomes considered included rates of neurologic and sensory abnormality, Mental (MDI) and Psychomotor Developmental Index scores on BSID II, and rates of neurodevelopmental impairment defined as neurosensory impairment and/or an MDI score of less than 70. Logistic regression was used to examine the association between sociodemographic and individual neonatal risk factors on outcomes. In these analyses, sex, social risk, and birth weight were included as covariates. In separate logistic analyses, all neonatal risk factors, as well as sex, social risk, and birth weight, were considered as predictors of outcome and were selected for a final model using forward stepwise regression.

NEUROSENSORY AND DEVELOPMENTAL OUTCOMES

Information concerning the neurosensory outcomes is presented in Table 3, and the results of the BSID II are presented in Table 4. Twenty percent of the children had a major neurologic abnormality and 42%, a subnormal (<70) MDI score. Overall, 105 children (48%) had neurodevelopmental impairment (defined as a subnormal MDI score, neurologic abnormality, blindness, or deafness). Sixty-one children (28%) had 1 impairment; 28 (13%), 2 impairments; 13 (6%), 3 impairments; and 3 (1%), 4 impairments.

Table Graphic Jump LocationTable 3. 20-Month Neurosensory Outcomes*
Table Graphic Jump LocationTable 4. 20-Month Developmental Outcomes*

There were no significant differences in outcomes between the 68 children (31%) who weighed from 500 to 749 g at birth and the 153 (69%) who weighed from 750 to 999 g. Fifty-eight (38%) of the 750-999-g birth-weight group had an MDI score of less than 70 vs 34 (50%) of the group with birth weights of less than 750; 22 (14%) vs 11 (16%), respectively, had cerebral palsy; and 26 (17%) vs 18 (26%), respectively, had overall neurologic abnormality. Blindness occurred in 1 child in each group (1% each) and hearing loss in 13 (9%) vs 7 (10%) children, respectively.

There were also no differences in outcomes of the 171 children of appropriate size for gestational age and 50 small for gestational age (birth weight, <−2 SD13). Sixty-nine (40%) of the children of appropriate size for gestational age had an MDI score of less than 70 vs 23 (46%) of the children small for gestational age; 33 (19%) vs 11 (22%), respectively, had overall neurologic abnormality; and 17 (10%) vs 3 (6%), respectively, had deafness.

Figure 1 and Figure 2 illustrate the 100-g birth weight and gestational age–specific rates of neurodevelopmental impairment. The gestational age-specific outcomes pertain only to children with birth weights of less than 1000 g. Outcomes of the 28 children of at least 29 weeks' gestation are not presented, as the number of children at each of these ages was too small to provide meaningful results.

Place holder to copy figure label and caption
Figure 1.

Birth-weight–specific rates of subnormal Mental Developmental Index (MDI) score, neurologic abnormality (cerebral palsy, hypotonia, hypertonia, and shunt-dependent hydrocephalus), deafness, and impairment (neurodevelopmental impairment including an MDI score <70, neurologic abnormality, blindness, and deafness). The single child with birth weight of less than 500 g had no neurodevelopmental impairment.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 2.

Gestational age-specific rates of subnormal Mental Developmental Index (MDI) score, neurologic abnormality (cerebral palsy, hypotonia, hypertonia, and shunt-dependent hydrocephalus), deafness, and impairment (neurodevelopmental impairment including an MDI score <70, neurologic abnormality, blindness, and deafness). Outcomes of 28 children with gestational ages above 28 weeks are not included in the figure.

Graphic Jump Location

Multiple birth, Caesarean section, antenatal steroid therapy, and a history of amnionitis had no measurable effect on outcomes. The association of the various individual neonatal risk factors to outcomes, controlling for sex, social risk, and birth weight, are presented in Table 5. In addition to postnatal steroid therapy, controlling for chronic lung disease was predictive of a subnormal MDI score (odds ratio [OR], 2.47; 95% confidence interval [CI], 1.25-4.89) and neurologic abnormality (OR, 4.49; 95% CI, 1.66-12.14).

Table Graphic Jump LocationTable 5. Associations of Individual Neonatal Risk Factors With Outcomes*

Results of the multiple step-wise logistic regression analysis are presented in Table 6. Significant predictors of a subnormal MDI score were male sex, social risk, and chronic lung disease; of neurologic abnormality, abnormal ultrasound findings and chronic lung disease; and of deafness, male sex, sepsis, and jaundice.

Table Graphic Jump LocationTable 6. Results of Multiple Stepwise Logistic Regression as Significant Predictors Outcomes*

Our study indicates that ELBW children born since 1992 have high rates of neurosensory and developmental abnormality in early childhood. Neurosensory impairments prevalent in this population include cerebral palsy in 15% and deafness in 9%. As can be expected, most children with major neurosensory impairments have subnormal cognitive development. However, developmental outcomes are poor even for children free of major neurosensory impairments, of whom 62% have subnormal or borderline MDI scores on the BSID II. Although gestational age–specific outcomes improved at 28 weeks' gestation, there were very few differences in outcomes when the children were examined by 100-g birth-weight groups. Social and biological (sex and neonatal) risk factors predicted a subnormal MDI score, whereas neurologic abnormality and deafness were predicted by biological risk factors only.

Our results are in general agreement with those from the NICHD multicenter study in which 17% of the children had cerebral palsy, 11% had deafness, and 37% had subnormal cognitive scores.6 Of the 221 children described in our study, 102 also participated in the NICHD study. Other studies from the United States,10 Canada,12 Sweden,7 Australia9 and New Zealand11 that pertain to ELBW children born during 1990 through 1992 report better outcomes similar to those of ELBW children born during the late 1970s and 1980s, including cerebral palsy in 7% to 10% and subnormal cognitive function in 10% of children.10,12,2123

The reason for the poorer outcomes for children born since 1992 is unclear. Lorenz et al24 recently reported on the association of neurologic impairments with increased survival rates. Our survival rate of 72% at 20 months' corrected age for children born during 1992 through 1995 exceeds those of 60%, 57%, and 56% for children born during 1990 through 1992 in Canada,12 Sweden,7 and Australia,9 respectively. Increased survival is also associated with an increase in chronic lung disease,2,25 which together with the use of postnatal steroid therapy also might have contributed to the poorer neurodevelopmental outcomes.26,27 Children unavailable for follow-up are at greatest risk for neurodevelopmental problems.28,29 Our excellent return rate of 92% might have ensured the inclusion of such children, contributing to more negative overall outcomes.

Additional factors that might explain our outcomes are the relatively high rate of social risks for our population3032 and the inclusion of outborn infants, ie, infants transported to our neonatal intensive care unit after birth.33 Compared with the 185 children born at our perinatal center, the 36 outborn children had a higher rate of subnormal MDI score (58% vs 38%; P=.04) but similar rates of neurosensory abnormalities and overall impairment (58% vs 45%). Our tertiary urban perinatal center also includes an inner-city population with many social risk factors. The use of the BSID II since 1992 may partly explain our lower MDI scores but would not account for the relatively high rates of cerebral palsy and deafness.18,34 Longer follow-up to school age will be necessary to confirm these findings.

Factors that had a significant effect on the 20-month outcomes in our study include male sex, social risk, and the neonatal complications of severely abnormal cerebral findings on ultrasound, chronic lung disease, sepsis, and jaundice. We did not examine the independent effects of postnatal steroid therapy on outcome, as steroid use is closely associated with chronic lung disease and its severity. Additional factors that were not examined, but which have been reported to influence outcomes, include hypoglycemia, breast-milk feeding, and neonatal hypothyroxinemia.3537

The effect of sex is considered to be associated partly with the greater severity of illness in male infants.3842 Severely abnormal cerebral findings on ultrasound are well-recognized predictors of neurologic abnormality.6,4346 We presented the bivariate effects of the individual abnormal ultrasound findings, as they are used to counsel parents during the neonatal hospital stay (Table 5). The rates of neurodevelopmental impairment for children with a grade III or IV bleed, PVL, and persistent ventricular dilation were similar (69%, 75%, and 71%, respectively). These findings are in agreement with published reports.44,45,4749 However, such predictions are confounded by the co-occurrence of the various abnormal ultrasound findings.50 Nearly half of our children with PVL or persistent ventricular dilation also had a grade III or IV bleed. Our relatively small sample size did not allow for an examination of the effects of the severity and localization of the PVL or the degree of persistent ventricular dilation that may influence outcomes.44

Chronic lung disease is a recognized predictor of poor outcomes, even when controlling for other risk factors.6,43,5154 Factors contributing to these poor outcomes include periods of hypoxia, hypotension, and the detrimental effects of poor growth and prolonged hospitalization.

Our findings associated with deafness need to be interpreted with caution, since we did not routinely perform formal hearing tests; however, since deafness usually is diagnosed before 2 years of age, we doubt that any cases were missed. Sepsis is considered a marker for severe illness, which explains its high association with neurodevelopmental impairment, including deafness.38 The use of aminoglycosides to treat infants with sepsis may also have contributed to deafness.5557 The association between jaundice and deafness is considered to be due to bilirubin deposition in the brainstem.5861 Sepsis, a risk factor for the development of toxic effects of bilirubin, may have contributed to these effects.62,63

The prevention of prematurity and/or the improvement of the socioenvironmental milieu in which children develop, which could improve outcomes, seems at present to be unattainable in the United States.64 Furthermore, early enrichment programs, although beneficial, have not resulted in major improvements in the outcomes of the smallest preterm children.65,66 There is thus an urgent need for research into the etiology and prevention of neonatal morbidity. Ongoing surveillance is also mandatory to identify iatrogenic factors that may have deleterious effects on the outcome of ELBW children.

Accepted for publication December 20, 1999.

This study was supported in part by General Clinical Research Center grant MO1 RR00080 from the National Institutes of Health, National Center for Research Resources, Bethesda, Md.

We appreciate the help of Eloise Scott, Dee Kay Grant, and Bonnie Siner, RN, for research assistance; Nori Mercuri Minich for data analysis; and Cecily Lewis for secretarial assistance.

Corresponding author: Maureen Hack, MB, ChB, Division of Neonatology, Rainbow Babies and Childrens Hospital, 11100 Euclid Ave, Cleveland, OH 44106 (e-mail: mxh7@po.cwru.edu).

Fanaroff  AAWright  LLStevenson  DK  et al.  Very-low-birth-weight outcomes of the National Institute of Child Health and Human Developmental Neonatal Research Network, May 1991 through December 1992. Am J Obstet Gynecol. 1995;1731423- 1431
Link to Article
Stevenson  DKWright  LLLemons  JA  et al.  Very low birth weight outcomes of the National Institute of Child Health and Human Development Neonatal Research Network, January 1993 through December 1994. Am J Obstet Gynecol. 1998;1791632- 1639
Link to Article
The Investigators of the Vermont-Oxford Trials Network Database Project, The Vermont-Oxford Trials Network, Very low birth weight outcomes for 1990. Pediatrics. 1993;911- 6
Hack  MFriedman  HFanaroff  AA Outcomes of extremely low birth weight infants. Pediatrics. 1996;98931- 937
Hack  MFanaroff  AA Outcomes of children of extremely low birthweight and gestational age in the 1990's. Early Hum Dev. 1999;53193- 218
Link to Article
Vohr  BRDusick  ASteichen  JWright  LLVerter  JMele  L Neurodevelopmental and functional outcomes of extremely low birth weight infants in the National Institute of Child Health and Human Development Neonatal Research Network, 1993-1994. Pediatrics. 2000;1051216- 1226
Link to Article
Finnström  OOtterblad  PSedin  G  et al.  Neurosensory outcome and growth at three years in extremely low birthweight infants: follow-up results from the Swedish National Prospective Study. Acta Paediatr. 1998;871055- 1060
Link to Article
Blitz  RKWachtel  RCBlackmon  LBerenson-Howard  J Neurodevelopmental outcome of extremely low birth weight infants in Maryland. Md Med J. 1997;46 ((1)) 18- 24
The Victorian Infant Collaborative Study Group, Improved outcome into the 1990s for infants weighing 500-999 g at birth. Arch Dis Child Fetal Neonatal Ed. 1997;77F91- F94
Link to Article
Piecuch  RELeonard  CHCooper  BASehring  SA Outcome of extremely low birth weight infants (500 to 999 grams) over a 12-year period. Pediatrics. 1997;100633- 639
Link to Article
Dezoete  JAMacArthur  BAAftimos  S Developmental outcome at 18 months of children less than 1000 grams. N Z Med J. 1997;110205- 207
Robertson  CSauve  RSChristianson  HE Province-based study of neurologic disability among survivors weighing 500 through 1249 grams at birth. Pediatrics. 1994;93636- 640
Usher  RMcLean  F Intrauterine growth of live-born Caucasian infants at sea level: standards obtained from measurements in 7 dimensions of infants born between 25 and 44 weeks of gestation. Pediatrics. 1969;74901- 910
Link to Article
Hack  MBreslau  NWeissman  BAram  DKlein  NBorawski  E Effects of very low birth weight and subnormal head size on cognitive abilities at school age. N Engl J Med. 1991;325231- 237
Link to Article
Shennan  ATDunn  MSOhlsson  ALenox  K Abnormal pulmonary outcomes in premature infants: prediction from oxygen requirement in the neonatal period. Pediatrics. 1988;82527- 532
Bell  MJTernberg  JLFeigin  RD  et al.  Neonatal necrotizing enterocolitis: therapeutic decisions based on clinical staging. Ann Surg. 1978;1871- 7
Link to Article
Papile  LABurstein  JBurstein  RKoffler  H Incidence and evolution of subependymal and intraventricular hemorrhages: a study of infants with birthweights less than 1500 g. J Pediatr. 1978;92529- 534
Link to Article
Bayley  N Scales of Infant Development. 2nd ed. San Antonio, Tex The Psychological Corp1993;
Amiel-Tison  CStewart  AL Follow-up studies in the first five years of life: a pervasive assessment of neurologic function. Arch Dis Child. 1989;64496- 502
Link to Article
World Health Organization, International Classification of Impairments, Disabilities and Handicaps.  Geneva, Switzerland World Health Organization1980;
Saigal  SRosenbaum  PHattersley  BMilner  R Decreased disability rate among 3-year-old survivors weighing 501 to 1000 grams at birth and born to residents of a geographically defined region from 1981 to 1984 compared with 1977 to 1980. J Pediatr. 1989;114839- 846
Link to Article
Lee  K-SKim  BKhoshnood  B  et al.  Outcome of very low birth weight infants in industrialized countries: 1947-1987. Am J Epidemiol. 1995;1411188- 1193
French  NPParry  TSEvans  S Improving outcome for Western Australian infants with birthweights 500-999 g. Med J Aust. 1995;162295- 299
Lorenz  JMPaneth  NJetton  JRden Ouden  LTyson  JE Aggressive v expectant care of the extremely premature newborn: outcome and resource utilization [abstract]. Pediatr Res. 1999;45249A
Link to Article
Parker  RALindstrom  DPCotton  RB Improved survival accounts for most, but not all, of the increase in bronchopulmonary dysplasia. Pediatrics. 1992;90663- 668
O'Shea  TMKothadia  JMKlinepeter  KL  et al.  Randomized placebo-controlled trial of a 42-day tapering course of dexamethasone to reduce the duration of ventilator dependency in very low birth weight infants: outcome of study participants at 1-year adjusted age. Pediatrics. 1999;10415- 21
Link to Article
Yeh  TFLin  YJHuang  CCChen  YJTsai  WFLien  YJ Early dexamethasone therapy in preterm infants: a follow-up study. Pediatrics [serial online]. May1998;101e7
Tin  WFritz  SWariyar  UHey  E Outcome of very preterm birth: children reviewed with ease at 2 years differ from those followed up with difficulty. Arch Dis Child Fetal Neonatal Ed. 1998;79F83- F87
Link to Article
Turnbull  D Loss to follow-up of preterm and very preterm babies. Lancet. 1998;3521875- 1876
Link to Article
Bacharach  VRBaumeister  AA Effects of maternal intelligence, marital status, income, and home environment on cognitive development of low birthweight infants. J Pediatr Psychol. 1998;23197- 205
Link to Article
Bendersky  MLewis  M Environmental risk, biological risk, and developmental outcome. Dev Psychol. 1994;30484- 494
Link to Article
Landry  SHDenson  SESwank  PR Effects of medical risk and socioeconomic status on the rate of change in cognitive and social development for low birth weight children. J Clin Exp Neuropsychol. 1997;19261- 274
Link to Article
Lubchencho  LOButterfield  LJDelaney-Black  VGoldson  EKoops  BLLazotte  DC Outcome of very-low-birth-weight infants: does antepartum versus neonatal referral have a better impact on mortality, or long-term outcome? Am J Obstet Gynecol. 1989;160539- 545
Link to Article
Bayley  N Scales of Infant Development.  New York, NY The Psychological Corp1969;
Lucas  AMorley  RCole  TJGore  SM A randomised multicentre study of human milk versus formula and later development in preterm infants. Arch Dis Child Fetal Neonatal Ed. 1994;70F141- F146
Link to Article
Lucas  AMorley  RCole  TJ Adverse neurodevelopmental outcome of moderate neonatal hypoglycaemia. BMJ. 1988;2971304- 1308
Link to Article
Reuss  MLPaneth  NPinto-Martin  JALorenz  JMSusser  M The relation of transient hypothyroxinemia in preterm infants to neurologic development at two years of age. N Engl J Med. 1996;334821- 827
Link to Article
Msall  MEBuck  GMRogers  BT  et al.  Multivariate risks among extremely premature infants. J Perinatol. 1994;1441- 47
Verloove-Vanhorick  SPVeen  SEns-Dokkum  MHSchreuder  AMBrand  RRuys  JH Sex difference in disability and handicap at five years of age in children born at very short gestation. Pediatrics. 1994;93576- 579
Largo  RHMolinari  LKundu  SHunziker  UDuc  G Neurological outcome in high risk weight appropriate for gestational age preterm children at early school age. Eur J Pediatr. 1990;149835- 844
Link to Article
Resnick  MBRoth  JAriet  M  et al.  Educational outcome of neonatal intensive care graduates. Pediatrics. 1992;89373- 378
Brothwood  MWolke  DGamsu  HBenson  JCooper  D Prognosis of the very-low-birthweight baby in relation to gender. Arch Dis Child. 1986;61559- 564
Link to Article
Hack  MTaylor  HGKlein  NEiben  RSchatschneider  CMercuri Minich  N School age outcome of a regional cohort of <750 gm birthweight children. N Engl J Med. 1994;331753- 759
Link to Article
Holling  EELeviton  A Characteristics of cranial ultrasound echolucencies that predict disability: a review. Dev Med Child Neurol. 1999;41136- 139
Link to Article
Stewart  AKirkbride  V Very preterm infants at fourteen years: relationship with neonatal ultrasound brain scans and neurodevelopmental status at one year. Acta Paediatr Suppl. 1996;41644- 47
Link to Article
Whitaker  AHFeldman  JFVan Rossem  R  et al.  Neonatal cranial ultrasound abnormalities in low birth weight infants: relation to cognitive outcomes at six years of age. Pediatrics. 1996;98719- 729
Ment  LRVohr  BOh  W  et al.  Neurodevelopmental outcome at 36 months' corrected age of preterm infants in the multicenter Indomethacin Intraventricular Hemorrhage Prevention Trial. Pediatrics. 1996;98714- 718
Ment  LRVohr  BAllan  W  et al.  Etiology and outcome of cerebral ventriculomegaly at term in very low birth weight preterm infants. Pediatrics. 1999;104243- 248
Link to Article
Vohr  BColl  CGFlanagan  POh  W Effects of intraventricular hemorrhage and socioeconomic status on perceptual, cognitive and neurologic status of low birth weight infants at 5 years of age. J Pediatr. 1992;121280- 285
Link to Article
Kuban  KSanocka  ULeviton  A  et al.  White matter disorders of prematurity: association with intraventricular hemorrhage and ventriculomegaly. J Pediatr. 1999;134539- 546
Link to Article
Skidmore  MDRivers  AHack  M Increased risk of cerebral palsy among very low-birthweight infants with chronic lung disease. Dev Med Child Neurol. 1990;32325- 332
Link to Article
O'Shea  TMGoldstein  DJdeRegnier  R-ASheaffer  CIRoberts  DDDillard  RG Outcome at 4 to 5 years of age in children recovered from neonatal chronic lung disease. Dev Med Child Neurol. 1996;38830- 839
Gray  PHBurns  YRMohay  HAO'Callaghan  MJTudehope  DI Neurodevelopmental outcome of preterm infants with bronchopulmonary dysplasia. Arch Dis Child Fetal Neonatal Ed. 1995;73F128- F134
Link to Article
Singer  LYamashita  TLilien  LCollin  MBaley  J A longitudinal study of developmental outcome of infants with bronchopulmonary dysplasia and very low birth weight. Pediatrics. 1998;100987- 993
Link to Article
Pettigrew  AGEdwards  DAHenderson-Smart  DJ Perinatal risk factors in preterm infants with moderate-to-profound hearing deficits. Med J Aust. 1988;148174- 177
Borradori  CFawer  C-LBuclin  TCalame  A Risk factors of sensorineural hearing loss in preterm infants. Biol Neonate. 1997;711- 10
Link to Article
Salamy  AEldredge  LTooley  WH Neonatal status and hearing loss in high-risk infants. J Pediatr. 1989;114847- 852
Link to Article
Karplus  MLee  CCashore  WJOh  W The effects of brain bilirubin deposition on auditory brain stem evoked responses in rats. Early Hum Dev. 1988;16185- 194
Link to Article
Bergman  IHirsch  RPFria  TJShapiro  SMHolzman  IPainter  MJ Cause of hearing loss in the high-risk premature infant. J Pediatr. 1985;10695- 101
Link to Article
Doyle  LWKeir  EKitchen  WH  et al.  Audiologic assessment of extremely low birth weight infants: a preliminary report. Pediatrics. 1992;90744- 749
de Vries  LSLary  SDubowitz  LMS Relationship of serum bilirubin levels to oxotoxicity and deafness in high-risk low-birth-weight infants. Pediatrics. 1985;76351- 354
Naeye  RL Amniotic fluid infections, neonatal hyperbilirubinemia, and psychomotor impairment. Pediatrics. 1978;62497- 503
Lucey  JF The unsolved problem of kernicterus in the susceptible low birth weight infant. Pediatrics. 1972;49646- 647
Ventura  SJMartin  JACurtin  SCMathews  TJ Report of final natality statistics, 1996. Monthly Vital Statistics Report. No. 11 Hyattsville, Md National Center for Health Statistics1998;46
The Avon Premature Infant Project, A randomised trial of parental support for families with very preterm children. Arch Dis Child Fetal Neonatal Ed. 1998;79F4- F11
Link to Article
Infant Health and Development Program, Enhancing the outcomes of low birth weight, premature infants: a multisite, randomized trial. JAMA. 1990;2633035- 3042
Link to Article

Figures

Place holder to copy figure label and caption
Figure 1.

Birth-weight–specific rates of subnormal Mental Developmental Index (MDI) score, neurologic abnormality (cerebral palsy, hypotonia, hypertonia, and shunt-dependent hydrocephalus), deafness, and impairment (neurodevelopmental impairment including an MDI score <70, neurologic abnormality, blindness, and deafness). The single child with birth weight of less than 500 g had no neurodevelopmental impairment.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 2.

Gestational age-specific rates of subnormal Mental Developmental Index (MDI) score, neurologic abnormality (cerebral palsy, hypotonia, hypertonia, and shunt-dependent hydrocephalus), deafness, and impairment (neurodevelopmental impairment including an MDI score <70, neurologic abnormality, blindness, and deafness). Outcomes of 28 children with gestational ages above 28 weeks are not included in the figure.

Graphic Jump Location

Tables

Table Graphic Jump LocationTable 1. Maternal Demographic Risk Factors and Infant Birth Data*
Table Graphic Jump LocationTable 2. Neonatal Risk Factors and Therapies*
Table Graphic Jump LocationTable 3. 20-Month Neurosensory Outcomes*
Table Graphic Jump LocationTable 4. 20-Month Developmental Outcomes*
Table Graphic Jump LocationTable 5. Associations of Individual Neonatal Risk Factors With Outcomes*
Table Graphic Jump LocationTable 6. Results of Multiple Stepwise Logistic Regression as Significant Predictors Outcomes*

References

Fanaroff  AAWright  LLStevenson  DK  et al.  Very-low-birth-weight outcomes of the National Institute of Child Health and Human Developmental Neonatal Research Network, May 1991 through December 1992. Am J Obstet Gynecol. 1995;1731423- 1431
Link to Article
Stevenson  DKWright  LLLemons  JA  et al.  Very low birth weight outcomes of the National Institute of Child Health and Human Development Neonatal Research Network, January 1993 through December 1994. Am J Obstet Gynecol. 1998;1791632- 1639
Link to Article
The Investigators of the Vermont-Oxford Trials Network Database Project, The Vermont-Oxford Trials Network, Very low birth weight outcomes for 1990. Pediatrics. 1993;911- 6
Hack  MFriedman  HFanaroff  AA Outcomes of extremely low birth weight infants. Pediatrics. 1996;98931- 937
Hack  MFanaroff  AA Outcomes of children of extremely low birthweight and gestational age in the 1990's. Early Hum Dev. 1999;53193- 218
Link to Article
Vohr  BRDusick  ASteichen  JWright  LLVerter  JMele  L Neurodevelopmental and functional outcomes of extremely low birth weight infants in the National Institute of Child Health and Human Development Neonatal Research Network, 1993-1994. Pediatrics. 2000;1051216- 1226
Link to Article
Finnström  OOtterblad  PSedin  G  et al.  Neurosensory outcome and growth at three years in extremely low birthweight infants: follow-up results from the Swedish National Prospective Study. Acta Paediatr. 1998;871055- 1060
Link to Article
Blitz  RKWachtel  RCBlackmon  LBerenson-Howard  J Neurodevelopmental outcome of extremely low birth weight infants in Maryland. Md Med J. 1997;46 ((1)) 18- 24
The Victorian Infant Collaborative Study Group, Improved outcome into the 1990s for infants weighing 500-999 g at birth. Arch Dis Child Fetal Neonatal Ed. 1997;77F91- F94
Link to Article
Piecuch  RELeonard  CHCooper  BASehring  SA Outcome of extremely low birth weight infants (500 to 999 grams) over a 12-year period. Pediatrics. 1997;100633- 639
Link to Article
Dezoete  JAMacArthur  BAAftimos  S Developmental outcome at 18 months of children less than 1000 grams. N Z Med J. 1997;110205- 207
Robertson  CSauve  RSChristianson  HE Province-based study of neurologic disability among survivors weighing 500 through 1249 grams at birth. Pediatrics. 1994;93636- 640
Usher  RMcLean  F Intrauterine growth of live-born Caucasian infants at sea level: standards obtained from measurements in 7 dimensions of infants born between 25 and 44 weeks of gestation. Pediatrics. 1969;74901- 910
Link to Article
Hack  MBreslau  NWeissman  BAram  DKlein  NBorawski  E Effects of very low birth weight and subnormal head size on cognitive abilities at school age. N Engl J Med. 1991;325231- 237
Link to Article
Shennan  ATDunn  MSOhlsson  ALenox  K Abnormal pulmonary outcomes in premature infants: prediction from oxygen requirement in the neonatal period. Pediatrics. 1988;82527- 532
Bell  MJTernberg  JLFeigin  RD  et al.  Neonatal necrotizing enterocolitis: therapeutic decisions based on clinical staging. Ann Surg. 1978;1871- 7
Link to Article
Papile  LABurstein  JBurstein  RKoffler  H Incidence and evolution of subependymal and intraventricular hemorrhages: a study of infants with birthweights less than 1500 g. J Pediatr. 1978;92529- 534
Link to Article
Bayley  N Scales of Infant Development. 2nd ed. San Antonio, Tex The Psychological Corp1993;
Amiel-Tison  CStewart  AL Follow-up studies in the first five years of life: a pervasive assessment of neurologic function. Arch Dis Child. 1989;64496- 502
Link to Article
World Health Organization, International Classification of Impairments, Disabilities and Handicaps.  Geneva, Switzerland World Health Organization1980;
Saigal  SRosenbaum  PHattersley  BMilner  R Decreased disability rate among 3-year-old survivors weighing 501 to 1000 grams at birth and born to residents of a geographically defined region from 1981 to 1984 compared with 1977 to 1980. J Pediatr. 1989;114839- 846
Link to Article
Lee  K-SKim  BKhoshnood  B  et al.  Outcome of very low birth weight infants in industrialized countries: 1947-1987. Am J Epidemiol. 1995;1411188- 1193
French  NPParry  TSEvans  S Improving outcome for Western Australian infants with birthweights 500-999 g. Med J Aust. 1995;162295- 299
Lorenz  JMPaneth  NJetton  JRden Ouden  LTyson  JE Aggressive v expectant care of the extremely premature newborn: outcome and resource utilization [abstract]. Pediatr Res. 1999;45249A
Link to Article
Parker  RALindstrom  DPCotton  RB Improved survival accounts for most, but not all, of the increase in bronchopulmonary dysplasia. Pediatrics. 1992;90663- 668
O'Shea  TMKothadia  JMKlinepeter  KL  et al.  Randomized placebo-controlled trial of a 42-day tapering course of dexamethasone to reduce the duration of ventilator dependency in very low birth weight infants: outcome of study participants at 1-year adjusted age. Pediatrics. 1999;10415- 21
Link to Article
Yeh  TFLin  YJHuang  CCChen  YJTsai  WFLien  YJ Early dexamethasone therapy in preterm infants: a follow-up study. Pediatrics [serial online]. May1998;101e7
Tin  WFritz  SWariyar  UHey  E Outcome of very preterm birth: children reviewed with ease at 2 years differ from those followed up with difficulty. Arch Dis Child Fetal Neonatal Ed. 1998;79F83- F87
Link to Article
Turnbull  D Loss to follow-up of preterm and very preterm babies. Lancet. 1998;3521875- 1876
Link to Article
Bacharach  VRBaumeister  AA Effects of maternal intelligence, marital status, income, and home environment on cognitive development of low birthweight infants. J Pediatr Psychol. 1998;23197- 205
Link to Article
Bendersky  MLewis  M Environmental risk, biological risk, and developmental outcome. Dev Psychol. 1994;30484- 494
Link to Article
Landry  SHDenson  SESwank  PR Effects of medical risk and socioeconomic status on the rate of change in cognitive and social development for low birth weight children. J Clin Exp Neuropsychol. 1997;19261- 274
Link to Article
Lubchencho  LOButterfield  LJDelaney-Black  VGoldson  EKoops  BLLazotte  DC Outcome of very-low-birth-weight infants: does antepartum versus neonatal referral have a better impact on mortality, or long-term outcome? Am J Obstet Gynecol. 1989;160539- 545
Link to Article
Bayley  N Scales of Infant Development.  New York, NY The Psychological Corp1969;
Lucas  AMorley  RCole  TJGore  SM A randomised multicentre study of human milk versus formula and later development in preterm infants. Arch Dis Child Fetal Neonatal Ed. 1994;70F141- F146
Link to Article
Lucas  AMorley  RCole  TJ Adverse neurodevelopmental outcome of moderate neonatal hypoglycaemia. BMJ. 1988;2971304- 1308
Link to Article
Reuss  MLPaneth  NPinto-Martin  JALorenz  JMSusser  M The relation of transient hypothyroxinemia in preterm infants to neurologic development at two years of age. N Engl J Med. 1996;334821- 827
Link to Article
Msall  MEBuck  GMRogers  BT  et al.  Multivariate risks among extremely premature infants. J Perinatol. 1994;1441- 47
Verloove-Vanhorick  SPVeen  SEns-Dokkum  MHSchreuder  AMBrand  RRuys  JH Sex difference in disability and handicap at five years of age in children born at very short gestation. Pediatrics. 1994;93576- 579
Largo  RHMolinari  LKundu  SHunziker  UDuc  G Neurological outcome in high risk weight appropriate for gestational age preterm children at early school age. Eur J Pediatr. 1990;149835- 844
Link to Article
Resnick  MBRoth  JAriet  M  et al.  Educational outcome of neonatal intensive care graduates. Pediatrics. 1992;89373- 378
Brothwood  MWolke  DGamsu  HBenson  JCooper  D Prognosis of the very-low-birthweight baby in relation to gender. Arch Dis Child. 1986;61559- 564
Link to Article
Hack  MTaylor  HGKlein  NEiben  RSchatschneider  CMercuri Minich  N School age outcome of a regional cohort of <750 gm birthweight children. N Engl J Med. 1994;331753- 759
Link to Article
Holling  EELeviton  A Characteristics of cranial ultrasound echolucencies that predict disability: a review. Dev Med Child Neurol. 1999;41136- 139
Link to Article
Stewart  AKirkbride  V Very preterm infants at fourteen years: relationship with neonatal ultrasound brain scans and neurodevelopmental status at one year. Acta Paediatr Suppl. 1996;41644- 47
Link to Article
Whitaker  AHFeldman  JFVan Rossem  R  et al.  Neonatal cranial ultrasound abnormalities in low birth weight infants: relation to cognitive outcomes at six years of age. Pediatrics. 1996;98719- 729
Ment  LRVohr  BOh  W  et al.  Neurodevelopmental outcome at 36 months' corrected age of preterm infants in the multicenter Indomethacin Intraventricular Hemorrhage Prevention Trial. Pediatrics. 1996;98714- 718
Ment  LRVohr  BAllan  W  et al.  Etiology and outcome of cerebral ventriculomegaly at term in very low birth weight preterm infants. Pediatrics. 1999;104243- 248
Link to Article
Vohr  BColl  CGFlanagan  POh  W Effects of intraventricular hemorrhage and socioeconomic status on perceptual, cognitive and neurologic status of low birth weight infants at 5 years of age. J Pediatr. 1992;121280- 285
Link to Article
Kuban  KSanocka  ULeviton  A  et al.  White matter disorders of prematurity: association with intraventricular hemorrhage and ventriculomegaly. J Pediatr. 1999;134539- 546
Link to Article
Skidmore  MDRivers  AHack  M Increased risk of cerebral palsy among very low-birthweight infants with chronic lung disease. Dev Med Child Neurol. 1990;32325- 332
Link to Article
O'Shea  TMGoldstein  DJdeRegnier  R-ASheaffer  CIRoberts  DDDillard  RG Outcome at 4 to 5 years of age in children recovered from neonatal chronic lung disease. Dev Med Child Neurol. 1996;38830- 839
Gray  PHBurns  YRMohay  HAO'Callaghan  MJTudehope  DI Neurodevelopmental outcome of preterm infants with bronchopulmonary dysplasia. Arch Dis Child Fetal Neonatal Ed. 1995;73F128- F134
Link to Article
Singer  LYamashita  TLilien  LCollin  MBaley  J A longitudinal study of developmental outcome of infants with bronchopulmonary dysplasia and very low birth weight. Pediatrics. 1998;100987- 993
Link to Article
Pettigrew  AGEdwards  DAHenderson-Smart  DJ Perinatal risk factors in preterm infants with moderate-to-profound hearing deficits. Med J Aust. 1988;148174- 177
Borradori  CFawer  C-LBuclin  TCalame  A Risk factors of sensorineural hearing loss in preterm infants. Biol Neonate. 1997;711- 10
Link to Article
Salamy  AEldredge  LTooley  WH Neonatal status and hearing loss in high-risk infants. J Pediatr. 1989;114847- 852
Link to Article
Karplus  MLee  CCashore  WJOh  W The effects of brain bilirubin deposition on auditory brain stem evoked responses in rats. Early Hum Dev. 1988;16185- 194
Link to Article
Bergman  IHirsch  RPFria  TJShapiro  SMHolzman  IPainter  MJ Cause of hearing loss in the high-risk premature infant. J Pediatr. 1985;10695- 101
Link to Article
Doyle  LWKeir  EKitchen  WH  et al.  Audiologic assessment of extremely low birth weight infants: a preliminary report. Pediatrics. 1992;90744- 749
de Vries  LSLary  SDubowitz  LMS Relationship of serum bilirubin levels to oxotoxicity and deafness in high-risk low-birth-weight infants. Pediatrics. 1985;76351- 354
Naeye  RL Amniotic fluid infections, neonatal hyperbilirubinemia, and psychomotor impairment. Pediatrics. 1978;62497- 503
Lucey  JF The unsolved problem of kernicterus in the susceptible low birth weight infant. Pediatrics. 1972;49646- 647
Ventura  SJMartin  JACurtin  SCMathews  TJ Report of final natality statistics, 1996. Monthly Vital Statistics Report. No. 11 Hyattsville, Md National Center for Health Statistics1998;46
The Avon Premature Infant Project, A randomised trial of parental support for families with very preterm children. Arch Dis Child Fetal Neonatal Ed. 1998;79F4- F11
Link to Article
Infant Health and Development Program, Enhancing the outcomes of low birth weight, premature infants: a multisite, randomized trial. JAMA. 1990;2633035- 3042
Link to Article

Correspondence

CME
Meets CME requirements for:
Browse CME for all U.S. States
Accreditation Information
The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
Note: You must get at least of the answers correct to pass this quiz.
You have not filled in all the answers to complete this quiz
The following questions were not answered:
Sorry, you have unsuccessfully completed this CME quiz with a score of
The following questions were not answered correctly:
Commitment to Change (optional):
Indicate what change(s) you will implement in your practice, if any, based on this CME course.
Your quiz results:
The filled radio buttons indicate your responses. The preferred responses are highlighted
For CME Course: A Proposed Model for Initial Assessment and Management of Acute Heart Failure Syndromes
Indicate what changes(s) you will implement in your practice, if any, based on this CME course.
Submit a Comment

Multimedia

Some tools below are only available to our subscribers or users with an online account.

Web of Science® Times Cited: 209

Related Content

Customize your page view by dragging & repositioning the boxes below.

Articles Related By Topic
Related Collections
PubMed Articles