Search

OBJECTIVES: To describe the spectrum of cognitive outcomes of children with and without cerebral palsy (CP) after neonatal encephalopathy, evaluate the prognostic value of early developmental testing and report on school services and additional therapies. METHODS: The participants of this study are the school-aged survivors of the National Institute of Child Health and Human Development Neonatal Research Network randomized controlled trial of whole-body hypothermia. Children underwent neurologic examinations and neurodevelopmental and cognitive testing with the Bayley Scales of Infant Development–II at 18 to 22 months and the Wechsler intelligence scales and the Neuropsychological Assessment–Developmental Neuropsychological Assessment at 6 to 7 years. Parents were interviewed about functional status and receipt of school and support services. We explored predictors of cognitive outcome by using multiple regression models. RESULTS: Subnormal IQ scores were identified in more than a quarter of the children: 96% of survivors with CP had an IQ 84 (95% confidence interval, −49.3 to −35.0; P < .001). Twenty percent of children with normal IQ and 28% of those with IQ scores of 70 to 84 received special educational support services or were held back ≥1 grade level. CONCLUSIONS: Cognitive impairment remains an important concern for all children with neonatal encephalopathy.

Most neonatal outcome studies have focused on extremely premature or very-low-birth-weight infants. Limited long-term outcome data are available for infants born at 32- to 36-week gestation. This study compared test scores, teacher evaluations, individualized education programs (IEPs), and special educational services from kindergarten (K) to fifth grade in 970 preterm infants, including moderate preterm (MP) infants born at 32- to 33-week gestation and late preterm (LP) infants born at 34 to 36 weeks, and 13,671 full-term (FT) control infants. None of those studied had had neonatal compromise that would have qualified them for developmental follow-up. In direct child assessment tests, LP infants scored lower than FT infants in reading but not in math in K and first grade. For teacher academic rating scale scores, LP infants in multiple grades scored lower than FT infants for both reading and math. LP infants also had a greater need than those in the FT group for individualized education programs and special education services. MP infants scored lower for reading in K and grades 1 and 5 and lower for math at all grade levels. For teacher academic rating scale scores, MP infants in all post-K grades had worse reading and math skills than LP or FT infants. Compared with FT infants, twice as many MP infants required special education at all grade levels. After adjusting for gender, race, and maternal educational level, LP infants in the first grade were substantially likelier to have below-average scores in both reading and math than FT infants. MP infants had a similar adjusted risk for below average reading and math test scores compared to FT infants. The risk of poor school outcomes remained significant when only singleton LP infants were analyzed. These findings demonstrate that infants born at 32- to 36-week gestation are more likely than full-term infants to have poor school outcomes when evaluated from kindergarten to grade 5. All preterm infants are at risk and would benefit from follow-up, anticipatory guidance, and appropriate intervention.

Advances in perinatal/neonatal medicine in recent years, including surfactant in particular, have increased the chances of survival for extremely preterm, extremely low-birth-weight infants. Comparatively little, however,is known about neurosensory and developmental impairments in survivors. This study examined outcomes at corrected ages of 18 to 22 months for infants born in the 1990s whose estimated gestational age was less than 25 weeks and who weighed 501 to 1000 g at birth. The multicenter, retrospective, comparative analysis compared 366 infants born in 1993 to 1996 (epoch I) with 473 born in 1996 to 1999 (epoch II). Logistic regression analysis was used to determine the independent risk of cerebral palsy, a Mental Development Index (MDI) less than 70, a Psychomotor Development Index (PDI) less than 70, and neurodevelopmental impairment. Prenatal antibiotic treatment, steroid treatment, and cesarean section all were more frequent in epoch II, and 5-minute Apgar scores below 5 were significantly less frequent for these infants. Both surfactant and prophylactic indomethacin were used significantly more often in epoch II. Bronchopulmonary dysplasia, defined as a need for supplemental oxygen at 36 weeks of postconceptional age, was more frequent in epoch II, as was retinopathy of prematurity. Diagnoses more frequent in epoch I included patent ductus arteriosis, necrotizing enterocolitis, and grade III or grade IV intraventricular hemorrhage (IVH). There were no substantial differences between epochs in major neurosensory outcomes (Table 1). Cerebral palsy (CP) developed in just over half of infants in each epoch. In both periods, 21% of infants were considered not to be impaired because of no CP, deafness, or blindness and MDI and PDI scores of 85 or higher. On regression analysis, epoch was not an independent risk factor for CP or low PDI scores, but the risk of an MDI score below 70 was lower in the earlier epoch. Epoch was not an independent risk factor for being unimpaired. Significant factors included male gender, grade III or IV IVH, and postnatal steroid treatment. Early childhood neurodevelopmental outcomes for infants of less than 25 weeks estimated gestational age are not improving despite more aggressive treatment. Studies of later childhood status are needed to learn whether these infants are at risk of severe cognitive impairment.