Neonatal neurological examination of late preterm babies

Backgrounds

Healthy late-preterm (LP) infants examined at term equivalent age showed wider median and range of neurological scores than full-term infants; differences between infants born at 34 and those born at 35–36 weeks were also observed.

Aims

The aim of this study is to establish the range and frequency distribution of neonatal neurological scores in a cohort of low risk LP infants assessed during the first 3 days from birth.

Study design and subjects

118 low-risk infants born between 34 and 36 weeks of gestational age (GA) were assessed between 48 and 72 h from birth.

Outcome measures

The full version of the Hammersmith Neonatal Neurologic Assessment and the screening proforma were used to assess all the infants. The raw scores obtained were compared to those of full-term infants using the same examination.

Results

The distribution of neurological scores was similar among the 3 GAs for 26 items, with different median scores among LP infants born at 36 weeks and those born at 34 and 35 in only 2 items.LP infants showed a wider range of findings for each item than that of full term infants assessed soon after birth. Using the screening proforma, in our cohort, for each item the findings falling outside the 90% level were identical to those found in term-born and very preterm infants assessed at term age.

Conclusions

The neurological scores obtained in our cohort could help as reference data when examining LP infants at birth compared to age matched low risk infants.     

Neurological examination in healthy term infants aged 3-10 weeks

OBJECTIVES: The neurodevelopmental progress of newborn term infants is checked routinely at around 6 weeks of postnatal age. The maturation of neurological signs in this age range however has not been systematically studied and normative data are not available. The aim of this study was to document any changes in posture, tone, reflexes, behaviour and movements in low-risk full-term infants between 3 and 10 weeks of postnatal age. STUDY DESIGN: We performed a structured neurological examination previously standardised in full-term newborns in the first 48 h after birth. In the current study, a total of 76 examinations were performed between 3 and 10 weeks of age in low-risk full-term infants. RESULTS: The results of the examinations were divided according to postnatal age. In most items, the scores changed with time, with a definite shift in their distribution occurring around 6 weeks. At this age, a reduction in flexor tone of the limbs was observed, together with an increase in active neck tone. Visual orientation in contrast had already improved by 3 weeks when all infants were able to follow a target in a full circle compared to newborns that are often only able to follow a target in an arc. CONCLUSIONS: Our results suggest that 6 weeks post-term birth is an important milestone for changes in neurological signs, particularly those related to muscle tone and posture, probably reflecting maturation of the nervous system. These findings provide important guidelines for the interpretation of the neurological examination performed at this age.     

早产儿胼胝体生长率与智力运动发育的相关性研究

目的 通过超声检测VLBW早产儿胼胝体生长率,为早期评价和改善脑发育提供参考。方法 选取120例胎龄小于33周早产儿,分为26~29+6周组(64例),30~32+6周组(56例),比较两组胼胝体生长率,分析胼胝体长度与小脑蚓部长度之间的关系,胼胝体生长率与临床因素的关系及其与智能发育之间的关系。结果 早产儿胼胝体生长率于生后2周下降,26~29+6周组患儿生后3周~、5周~及7周~纠正胎龄40周时胼胝体生长低于30~32+6周组(P< 0.05)。胼胝体长度与小脑蚓部长度之间呈性线正相关。小于胎龄儿(SGA)生后2周内胼胝体生长率较差(P< 0.05)。12例智力发育严重异常早产儿胼胝体生长率于生后3~6周低于非严重异常组;5例运动发育严重异常早产儿胼胝体生长率于生后3~6周低于非严重异常组(P< 0.05)。结论 早产儿生后2~6周胼胝体生长率下降,可使其发生神经运动发育严重异常的危险性增加。     

A national two year follow up study of extremely low birthweight infants born in 1996-1997

Objective: To study neurodevelopmental outcome in a two year cohort of extremely low birthweight (ELBW) infants at 18 months corrected age, to compare the development of the ELBW infant subcohort with that of control children, and to find risk factors associated with unfavourable outcome. Study design: All 211 surviving ELBW infants (birth weight < 1000 g) born in Finland in 1996–1997 were included in a national survey. The ELBW infants (n = 78) who were born and followed in Helsinki University Hospital belonged to a regional subcohort and were compared with a control group of 75 full term infants. A national follow up programme included neurological, speech, vision, and hearing assessments at 18 months of corrected age. Bayley infant scale assessment was performed on the subcohort and their controls at 24 months of age. Risk factors for unfavourable outcome were estimated using logistic and linear regression models. Results: The prevalence of cerebral palsy was 11%, of all motor impairments 24%, of ophthalmic abnormalities 23%, and of speech delay 42%. No impairment was found in 42% of children, and 18% were classified as severely impaired. The prevalence of ophthalmic abnormalities decreased with increasing birth weight and gestational age, but the prevalence of other impairments did not. In the subcohort, a positive correlation was found between the date of birth and Bayley scores. Conclusion: Ophthalmic abnormalities decreased with increasing birth weight and gestational age, but no other outcome differences were found between birthweight groups or in surviving ELBW infants born at 22–26 weeks gestation. The prognosis in the regional subcohort seemed to improve during the short study period, but this needs to be confirmed.     

支气管肺发育不良早产儿生后1年内神经行为发育的临床分析

目的 探讨支气管肺发育不良（BPD）对早产儿生后1年内神经行为发育的影响。方法 回顾性选取2017年9月至2019年12月间出生胎龄 < 34周，并完成纠正胎龄40周及3、6、12月龄神经行为发育随访的早产儿为研究对象。根据诊断分为BPD组（n=23）和非BPD组（n=27），比较两组患儿不同时点的神经行为发育结果。结果 BPD组与非BPD组患儿纠正胎龄40周时新生儿神经行为测定评分差异无统计学意义（P > 0.05）。Gesell发育量表中，BPD组纠正胎龄3、6、12月龄时精细动作、适应性行为、社交行为能区发育商（DQ）及总DQ低于非BPD组（P < 0.05）；两组患儿纠正胎龄6月龄时言语能区DQ高于纠正胎龄12月龄（P < 0.017），纠正胎龄6月龄时社交行为能区DQ高于纠正胎龄3月龄（P < 0.017），纠正胎龄12月龄时适应性行为能区DQ高于纠正胎龄3、6月龄（P < 0.017）。Bayley发育量表Ⅱ中，两组患儿各时点智力和运动发展指数差异无统计学意义（P > 0.05），纠正胎龄3月龄时智力发展指数高于纠正胎龄6、12月龄（P < 0.001）。结论 BPD早产儿在生后1年内较非BPD早产儿存在神经发育落后，临床需给予重视。     

早产儿胼胝体生长率与运动发育迟滞关系的研究

目的：研究早产儿胼胝体生长率与神经运动发育之间的关系。方法：2007年3～8月入住新生儿重症监护病区胎龄小于34周早产儿50例,于生后0~6周接受经前囟门矢状位颅脑超声探查，胼胝体长度测量为从膝部至压部。所有早产儿于校正胎龄3月时接受52项神经运动检查, 分析胼胝体生长率与神经运动检查结果之间的关系。结果：早产儿出生时的胼胝体平均长度为39.16 mm，生后头6周，胼胝体生长率平均1.05 mm/周；神经运动检查异常组早产儿(n=14)和神经运动检查正常组早产儿(n=36)0～2周胼胝体生长率差异无显著性意义，P>0.05, 但神经运动检查异常组早产儿2～3周和4～5周胼胝体生长率（0.68 mm/周和0.86 mm/周）慢于正常组早产儿（1.17 mm/周和1.12 mm/周），差异有显著性意义（P<0.05），合并2～6周总的生长率，异常组仍然慢于正常组（0.91 mm/周比1.15 mm/周），差异有显著性意义（P<0.01）。结论：床旁超声监测早产儿胼胝体生长发育切实可行，早产儿于校正胎龄3月时神经运动发育迟滞可能与2～6周龄时胼胝体生长率低下有关。     

Extremely low–birth–weight infants less than 901 g: development and behaviour after 4 years of life

In a long–term, prospective, control study, 20 extremely low–birth–weight (ELBW) infants with birth weights between 500 and 900 g (mean 755 (SD 109) g) and gestational ages between 24 and 30 weeks (mean 26.2 (SD 1.8) weeks) were compared with 20 full–term infants at 4 years of age for growth, health, development and quality of life. Four of 20 (20%) ELBW children had major neurological disorders, which were all identified at the 1–year assessment. Seventeen (85%) ELBW children had cognitive development, assessed with the Griffiths mental development scale, within the normal range for age but lower than for full–term controls. The greatest deviations between ELBW and full–term children were found in locomotor and visual–motor integration functions. Eight ELBW children in all (40%), four with recurrent respiratory tract infections after neonatal mechanical ventilation and the four children with major neurological disorders had a higher rate of visits to physicians and hospital admissions. The behavioural symptom interview showed an increased rate of hyperactivity and difficulties in concentrating but not of general behavioural deviations in the ELBW group. Only by school age can all aspects of an extremely early birth be evaluated, but at 4 years of age, 85% of the ELBW children in our group had a good quality of life according to Scheffzek's categorizations.     

Extremely low-birth-weight infants less than 901 g. Growth and development after one year of life

In a long-term prospective control study, 20 extremely low-birth-weight infants with birth weights between 500 and 900 g (mean 755±109 g) and gestational ages between 24 and 30 weeks (mean 26.2±1.8 weeks) were compared with 20 full-term infants, after the first year of life for growth, development and continuing morbidity after discharge from the intensive care unit. The total rate of neurological abnormalities was 17%; the rate of infantile post-haemmorrhagic hydrocephalus requiring shunt operations was 8.7%, while 13% had retinopathy of prematurity with vision deficit, but none was blind. The hospital readmission rate was 70%, but for most infants only one or a few readmissions were needed whereas three infants with chronic lung disorders required frequent hospital readmissions, mainly for respiratory infections. Apart from 4 infants with major cerebral neonatal complications, 16 of 20 extremely low-birth-weight infants (80%) showed development within the normal range at one year of age, although with delay in some areas in comparison with full-term control infants. Follow-up into preschool and school age is in progress. We cautiously suggest that the results at the one year follow-up do indicate a possible favourable long-term outcome for many of these extremely low-birth-weight infants with normal cognitive development and with no major neurological sequelae.     

34周以下早产儿宫外生长发育迟缓发生的影响因素

目的　研究34周以下早产儿宫外生长发育迟缓(EUGR)发生的相关因素。方法　选取<34周早产儿694例, 根据出院时体重分为EUGR组和非EUGR组, 回顾性分析两组早产儿的围生期资料、住院期间生长、营养摄入情况及相关合并症等资料。结果　694例早产儿中, 发生EUGR 284例(40.9%)。宫内生长发育迟缓(IUGR)患儿发生EUGR的比例明显高于非IUGR组(P<0.01); 极低出生体重儿发生EUGR比例明显高于非极低出生体重儿(P<0.01)。胎龄越小、出生体重越低的早产儿EUGR的发生率越高(P<0.01)。EUGR组早产儿禁食天数、静脉营养持续天数、首次肠内营养的日龄、全肠内营养的日龄均大于非EUGR组(P<0.01)。EUGR组患儿生后第1周蛋白质累积损失量与热卡累积损失量均大于非EUGR组(P<0.05)。EUGR组生后发生呼吸窘迫综合征、呼吸暂停、坏死性小肠结肠炎、败血症等并发症的比例高于非EUGR组(P<0.05)。Logistic回归分析显示, 出生体重、出生胎龄及IUGR是EUGR发生的独立危险因素。结论 34周以下早产儿EUGR发生率较高, 尤其是已经存在IUGR的早产儿或极低出生体重儿; 生后早期积极的营养支持, 预防呼吸暂停、败血症等并发症将会在一定程度上减少EUGR的发生。     

Preterm or small-for-gestational-age infants

In 166 full term, small-for-gestational-age (FT-SGA), 53 preterm, appropriate-for-gestational-age (PT-AGA), 27 PT-SGA and 206 FT-AGA infants a neurological examination at the age of 6 years was carried out. Data were collected on behaviour and school achievement. Major and minor neurological abnormalities were more frequent in the three low birth weight groups, especially in the PT-SGA group. Multivariate analysis showed that the development of major and minor neurological abnormalities was explained by a varying set of risk factors, in which besides prematurity and growth retardation, neonatal neurological condition, social class, neonatal course and interval complications were preponderant. The results suggest a temporal difference in potentially harmful factors: for neurological handicap early in pregnancy, for minor neurological dysfunction (MND) the second half of gestation and the first 2 years of life. No striking behavioural differences were found between the three low birth weight groups and the FT-AGA group; behaviour was related to neonatal and follow-up neurological condition, sex, gestational age and birth weight to a limited extent only. Three (4%) of the preterms entered a special school (already at the age of 6). School achievement was mainly related to the present neurological condition and social class, which underlines the importance of the latter.Abbreviations ADL activities of daily life - AGA appropriate-for-gestational age - FT full term - LBW low birth weight - MND minor neurological dysfunction - OOS obstetrical optimality score - OR Odds ratio - PT preterm - SGA small-forgestational age - VLBW very low birth weight     

Postural development in very low birth weight and normal birth weight infants

In this study the seven postural responses selected by Vojta to evaluate neuromotor development were applied to 68 very low birth weight (VLBW) (greater than 1500 g) infants and to 28 healthy infants of normal birth weight (less than 2500 g). Of the 68 VLBW infants, 41 were small for gestational age and 27 appropriate for gestational age. All infants were examined between 37 and 40 weeks postmenstrual age. They were all later assessed on the Griffiths Mental Developmental Scale at 12 and 18 months. There were significant differences in postural reactions between the two groups which confirmed the lower tone and greater extension previously described in very low birth weight infants. An important finding in the study was that poor head and trunk righting noted at four months corrected age in very low birth weight infants, was associated with less developed locomotion at 12 and 18 months as assessed by the Griffiths Mental Developmental Scale. Thus, a delay in maturation in very low birth weight infants which was apparent from the assessment of postural responses in early infancy was still identifiable on the locomotor subscales at 12 and 18 months. Five of Vojta's responses were shown to be useful as part of the neurological assessment of high risk infants.     

Human immunodeficiency virus infection and cerebral malaria in children in Uganda: a case-control study

Background

Standard values for birth weight by gestational age are not available for sub-Saharan Africa, but are needed to evaluate incidence and risk factors for intrauterine growth retardation in settings where HIV, antiretrovirals, and other in utero exposures may impact birth outcomes.

Methods

Birth weight data were collected from six hospitals in Botswana. Infants born to HIV-negative women between 26-44 weeks gestation were analyzed to construct birth weight for gestational age charts. These data were compared with published norms for black infants in the United States.

Results

During a 29 month period from 2007-2010, birth records were reviewed in real-time from 6 hospitals and clinics in Botswana. Of these, 11,753 live infants born to HIV-negative women were included in the analysis. The median gestational age at birth was 39 weeks (1^st quartile 38, 3^rd quartile 40 weeks), and the median birth weight was 3100 grams (1^st quartile 2800, 3^rd quartile 3400 grams). We constructed estimated percentile curves for birth weight by gestational age which demonstrate increasing slope during the third trimester and leveling off beyond 40 weeks. Compared with black infants in the United States, Botswana-born infants had lower median birth weight for gestational age from weeks 37 through 42 (p < .02).

Conclusions

We present birth weight for gestational age norms for Botswana, which are lower at term than norms for black infants in the United States. These findings suggest the importance of regional birth weight norms to identify and define risk factors for higher risk births. These data serve as a reference for Botswana, may apply to southern Africa, and may help to identify infants at risk for perinatal complications and inform comparisons among infants exposed to HIV and antiretrovirals in utero.     

早产儿脑额叶发育及其影响因素的研究

目的 应用三维超声技术探讨早产儿脑额叶发育及其影响因素.方法 选取222例无严重脑损伤的早产儿,应用三维超声对额叶体积进行测量.随访中分别在矫正年龄至40周、1个月、3个月、6个月及以后的时间进行全面的神经系统及体格发育检查,6个月内进行体积跟踪测定.结果 早产儿出生时额叶体积随胎龄的增加而增长.生后出现追赶性生长,在矫正年龄40周及1个月时增长最为迅速,达到甚至超过了足月儿,在以后的生长中逐渐落后于正常足月儿.早产儿成熟度越低,额叶体积越小,矫正年龄40周及以后的时间点,各组额叶体积数值相当,组间差异无统计学意义(P＞0.05).宫内外营养情况较差的早产儿额叶体积的生长始终落后于生长发育正常的早产儿(P＜0.05).额叶体积生长严重落后的早产儿出现神经发育重度异常的几率较正常早产儿明显升高(50%).结论 早产儿额叶体积随胎龄增长而增加,生后短期内出现追赶性生长,宫内外营养状况影响额叶发育,体积测定值的异常与神经发育异常有关.     

丰富环境早期干预对早产儿预后的影响

目的 研究早期丰富环境干预对早产儿预后的影响。方法 将胎龄30—36周、出生体重1700—2450g的106例早产儿随机分为早期丰富环境干预组(干预组)和普通环境干预组(对照组)，生后即开始不同环境干预，观察对早产儿出生后2周内呼吸、心率、神经行为评分、吸吮能力、睡眠的影响及对大运动、精细运动发育过程、语言发育过程、2岁内脏性瘫痪(CP)发生率影响。结果 干预组出生2周内呼吸、心率、睡眠较对照组平稳(P＜0．01)，吸吮能力较对照组强(P＜0．01)，神经行为评分高于对照组(P＜0．05)，干预组运动发育过程显著快于对照组，2岁内CP发生率显著低于对照组(P＜0.01)。结论 对早产儿应尽早开始早期丰富环境干预，以改善其预后。     

Postural complexity differs between infant born full term and preterm during the development of early behaviors

Background and aims

Postural control differs between infants born preterm and full term at 1–3 weeks of age. It is unclear if differences persist or alter the development of early behaviors. The aim of this longitudinal study was to compare changes in postural control variability during development of head control and reaching in infants born preterm and full term.

Methods

Eighteen infants born preterm (mean gestational age 28.3 ± 3.1 weeks) were included in this study and compared to existing data from 22 infants born full term. Postural variability was assessed longitudinally using root mean squared displacement and approximate entropy of the center of pressure displacement from birth to 6 months as measures of the magnitude of the variability and complexity of postural control. Behavioral coding was used to quantify development of head control and reaching.

Results

Group differences were identified in postural complexity during the development of head control and reaching. Infants born preterm used more repetitive and less adaptive postural control strategies than infants born full term. Both groups changed their postural complexity utilized during the development of head control and reaching.

Discussion

Early postural complexity was decreased in infants born preterm, compared to infants born full term. Commonly used clinical assessments did not identify these early differences in postural control. Altered postural control in infants born preterm influenced ongoing skill development in the first six months of life.     

The Incidence of Sleeping Problems in Preterm and Fullterm Infants Discharged from Neonatal Special Care Units: An Epidemiological Longitudinal Study

Abstract— Anecdotal reports have suggested that sleeping problems are a frequent complaint from parents of preterm infants. This prospective epidemiological study examined the incidence and stability of sleeping problems of very preterm (<32 weeks gestation at birth), preterm (32–36 weeks gestation) and fullterm infants, all admitted to special care baby units (SCBU) after birth, in comparison to healthy term infants over the first 5 years of life. Preterm infants were found to have fewer and shorter night-wakings at 5 months. No differences in sleeping behaviour compared with healthy term children were found at 20 and 56 months of age. Similar significant, and moderate, stability of nightwaking from one age to the next were found for exSCBU-graduates and healthy fullterm infants. Parental interventions such as staying the child until asleep and taking the infant into bed at night were related to nightwaking problems and increased parental distress. It is concluded that prematurity, and thus neurological immaturity and special care experience are less important than caretaking bf behaviour in the development of sleeping problems in both preterm and fullterm infants.     

Early prediction of neurological outcome by term neurological examination and cranial ultrasound in very preterm infants

Aim: To assess the value of term neurological examination and cranial ultrasound in the early prediction of neurological outcome at 12 months corrected age in a cohort of very preterm infants.
Methods: A cohort of 102 preterm infants born at <32 weeks gestation or with a birth weight of <1500 g were assessed using the Hammersmith Term Neurological Examination. They underwent cranial ultrasound examinations according to local guidelines. The Hammersmith Infant Neurological Examination was performed at 12 months corrected age. Scores for the term examinations were compared with scores derived from healthy infants born at term and with scores from low-risk preterm infants at term equivalent age. Term neurological scores and cranial ultrasound findings were compared in the prediction of 12-month neurological outcome.
Results: Seventy-eight (76.5%) preterm infants had suboptimal total neurological scores at term when compared to healthy infants born at term. However, most went on to have optimal neurological scores at 12 months corrected age. When our cohort was compared with low-risk preterm infants at term equivalent age only 14 (13.7%) scored outside the normal range. Neither system of scoring predicted neurological outcome at 12 months corrected age as reliably as cranial ultrasound (sensitivity 0.83, specificity 0.87).
Conclusion: Neurological examination of preterm babies at term may be unreliable in the prediction of neurological outcome at 12 months corrected age. For early prediction of neurological outcome cranial ultrasound examination was found to be more reliable.     

Morbidity and neurological function of very low birthweight infants from the newborn period to 4y of age. A prospective study from the south-east region of Sweden

All 107 infants weighing ≤1500 g at birth (VLBW) and born alive in the south-east region of Sweden during a 15-month period in 1987-88 were enrolled in a prospective study to determine the prevalence of handicap and to assess neurological function in comparison with controls. Eighty-six (80%) infants survived. Twenty (19%) had intracranial haemorrhages (ICH) assessed by ultrasound examinations in the neonatal period and 2 (2.3%) retinopathy of prematurity stage 3 or more. The VLBW infants who survived had fewer optimal neurological responses than the controls at 40 weeks post-conceptional age. Eighty-two VLBW children were followed to 4y of age. Three (4%) children had a neurological handicap and 9 (11%) had a moderate neurological deviation. Neither the size of ICH nor neonatal optimality score correlated to neurological outcome at 4 y of age. The VLBW children without neurological handicap or deviation (n = 70) had a delay in psychomotor development in comparison with the controls. Mental development and school performance, in particular language development, will be examined at school age.     

早期应用rhu-EPO对早产儿神经行为发育的影响

目的：评价重组人类基因促红细胞生成素(rhu-EPO)对早产儿神经行为发育的影响。方法：对44例早产儿（男30例,女14例）随机分为对照组、rhu-EPO治疗组,每组各22例,治疗组于生后第7天予rhu-EPO治疗4周,所有早产儿于纠正胎龄40周行新生儿行为神经检测(NBNA),生后6,12月用Gesell量表法进行神经发育评价。结果：①治疗组NBNA评分36.20±0.75分,高于对照组的34.40±1.05分(P<0.05);②治疗组Gesell发育量表在生后6月,治疗组精细动作的发育商高于对照组,在生后12月治疗组有3个能区（即大运动、精细动作和语言能区）的发育商高于对照组,差异有统计学意义（P<0.05）。结论：早期应用rhu-EPO可促进早产儿神经行为的发育。     

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 ? ?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.