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The Assessment of Preterm Infants' Behavior (APIB) is a newborn neurobehavioral assessment appropriate for preterm, at risk, and full-term newborns, from birth to 1 month after expected due date. The APIB is based in ethological--evolutionary thought and focuses on the assessment of mutually interacting behavioral subsystems in simultaneous interaction with the environment. The subsystems of functioning assessed include the autonomic (respiration, digestion, color), motor (tone, movement, postures), state organization (range, robustness, transition patterns), attention (robustness, transitions), and self-regulation (effort, success) systems as well as the degree of facilitation required to support reorganization and subsystem balance. The environment is represented by a sequence of distal, proximal, tactile, and vestibular challenges, derived from the BNBAS. The APIB conceptualizes infant competence as the degree of differentiation of subsystem function and degree of modulation of subsystem balance at any stage in infant development. Infants are understood as actively seeking their next differentiation, while counting on good enough environments to assure progressing developmental competence. In the case of interference such as premature birth, the mismatch of expectation and actual experience causes misalignment, which may become developmentally costly. The assessment is a finely tuned dialogue between examiner and infant, which requires training, skill and self-knowledge. The APIB has well established inter-rater-reliability, concurrent and construct validity, and is clinically relevant for behavioral intervention and individually appropriate and supportive care. (Contains 3 figures.)

This article describes the reflective process component of a multisite study of the effectiveness of family-focused, developmentally supportive care with low birthweight infants. Reflection is felt to be of particular value to developmental care because of the nature of the developmental approach itself, which is theory-guided, relationship-based, and systems-oriented. (Author/PB)

OBJECTIVE. MRI studies have shown that preterm infants with brain injury have altered brain tissue volumes. Investigation of preterm infants without brain injury offers the opportunity to define the influence of early birth on brain development and provide normative data to assess effects of adverse conditions on the preterm brain. In this study, we investigated serial MRI of low-risk preterm infants with the aim to identify regions of altered brain development. METHODS. Twenty-three preterm infants appropriate for gestational age without magnetic resonance-visible brain injury underwent MRI twice at 32 and at 42 weeks' postmenstrual age. Fifteen term infants were scanned 2 weeks after birth. Brain tissue classification and parcellation were conducted to allow comparison of regional brain tissue volumes. Longitudinal brain growth was assessed from preterm infants' serial scans. RESULTS. At 42 weeks' postmenstrual age, gray matter volumes were not different between preterm and term infants. Myelinated white matter was decreased, as were unmyelinated white matter volumes in the region including the central gyri. The gray matter proportion of the brain parenchyma constituted 30% and 37% at 32 and 42 weeks' postmenstrual age, respectively. CONCLUSIONS. This MRI study of preterm infants appropriate for gestational age and without brain injury establishes the influence of early birth on brain development. No decreased cortical gray matter volumes were found, which is in contrast to findings in preterm infants with brain injury. Moderately decreased white matter volumes suggest an adverse influence of early birth on white matter development. We identified a sharp increase in cortical gray matter volume in preterm infants' serial data, which may correspond to a critical period for cortical development. www.pediatrics.org/cgi/doi/10.1542/ peds.2005-2675 doi:10.1542/peds.2005 2675 Key Words magnetic resonance imaging, preterm infants, regional brain development, parcellation, segmentation Abbreviations UMWM--unmyelinated white matter MWM--myelinated white matter PMA--postmenstrual age AGA--appropriate for gestational age ICV--intracranial volume MR--magnetic resonance SPGR--spoiled gradient recalled CSF--cerebrospinal fluid CGM--cortical gray matter SGM--subcortical gray matter CPAR--cerebral parenchyma STAPLE--Simultaneous Truth and Performance Level Estimation ANCOVA--analysis of covariance, PRETERM INFANTS ARE at risk for adverse neurodevelopmental outcome and functional disabilities because of increased vulnerability of the brain before and after premature birth. (1,2) Brain injury, seen as white [...]

Objective. To investigate the effects of early experience on brain function and structure. Methods. A randomized clinical trial tested the neurodevelopmental effectiveness of the Newborn Individualized Developmental Care and Assessment Program (NIDCAP). Thirty preterm infants, 28 to 33 weeks" gestational age (GA) at birth and free of known developmental risk factors, participated in the trial. NIDCAP was initiated within 72 hours of intensive care unit admission and continued to the age of 2 weeks, corrected for prematurity. Control (14) and experimental (16) infants were assessed at 2 weeks' and 9 months' corrected age on health status, growth, and neurobehavior, and at 2 weeks' corrected age additionally on electroencephalogram spectral coherence, magnetic resonance diffusion tensor imaging, and measurements of transverse relaxation time. Results. The groups were medically and demographically comparable before as well as after the treatment. However, the experimental group showed significantly better neurobehavioral functioning, increased coherence between frontal and a broad spectrum of mainly occipital brain regions, and higher relative anisotropy in left internal capsule, with a trend for right internal capsule and frontal white matter. Transverse relaxation time showed no difference. Behavioral function was improved also at 9 months' corrected age. The relationship among the 3 neurodevelopmental domains was significant. The results indicated consistently better function and more mature fiber structure for experimental infants compared with their controls. Conclusions. This is the first in vivo evidence of enhanced brain function and structure due to the NIDCAP. The study demonstrates that quality of experience before term may influence brain development significantly. Pediatrics 2004;113:846-857; preterm infants, NIDCAP, neurobehavior, spectral coherence, diffusion tensor imaging, transverse relaxation time, Bayley Scales of Infant Development, APIB., The preterm infant provides an opportunity to study the effects of early postnatal experience on brain development. Increasing evidence suggests that features of brain structure (1-4) and function (5-8) are [...]

Individualized developmental care in intensive care nurseries may have beneficial effects on the infant's development. Individualized developmental care attempts to minimize the trauma and stress of care in intensive care nurseries by gentle handling and care that is more responsive to each particular infant's developmental needs. At two weeks past the infants' due date, researchers compared outcomes for 12 full-term infants treated normally, 12 healthy infants born between 30 and 34 weeks gestation given individualized developmental care, and 12 infants given standard nursery care. No differences were found for medical outcomes. However, preterm infants given standard care scored lower than infants given specialized care, and infants given specialized care had similar scores to full-term infants on measures of behavioral performance. Similarly, electroencephalopgraphic evaluation revealed that brain activity patterns were similar between preterm infants receiving specialized care and full-term infants and distinct from preterm infants receiving standard care., Objective. We assessed the effectiveness of individualized developmental support in the special care nursery for low-risk preterm infants. Setting. A university-affiliated teaching hospital. Participants. Twelve healthy full-term infants, and 24 low-risk preterm infants randomly assigned to a control or an experimental group. Design. The preterm control group received standard care and the preterm experimental group received individualized developmental care at the same special care nursery. Outcome Measures. Medical, behavioral (Assessment of Preterm Infants' Behavior and Prechtl's Neurological Examination of the Full-term Newborn Infant), and electrophysiologic outcome (using quantitative electroencephalography with topographic mapping) of all three groups was assessed 2 weeks after the expected due date. Results. No between- or among-group medical differences were seen for this low-risk, healthy sample. The preterm experimental group showed behavioral and electrophysiologic performances comparable to those of the full-term group, whereas the preterm control group performed significantly less well. Behavioral measures suggested significantly poorer attentional functioning for the preterm control group. Electrophysiologic results implicated the frontal lobe. Conclusions. Individualized developmental intervention supports neurobehavioral functioning as measured at 2 weeks post-term. It appears to prevent frontal lobe and attentional difficulties in the newborn period, the possible causes of behavioral and scholastic disabilities often seen in low-risk preterm infants at later ages., ABBREVIATIONS. LMP, last menstrual period; EDC, expected date of confinement; MDPI, Mean Daily Pulmonary Index; OCS, Obstetric Complications Scale Score; APIB, Assessment of Preterm Infants' Behavior; qEEG, quantitative electroencephalography; EP, [...]

Premature infants appear to benefit from individualized, developmentally oriented care. Premature, very-low-birthweight infants are at high risk of developing permanent cognitive and neurological problems. Some researchers have proposed that the neonatal intensive care unit may unexpectedly activate the infant's brain and interfere with normal neurological development. Thirty-eight premature infants were randomly assigned either to standard intensive care treatment (18 infants) or individualized, developmentally oriented care (20 infants). Those in the developmentally oriented group were cared for by specially trained nurses who learned to observe and respond to each infant's unique behaviors and to encourage infants to learn regulatory behaviors. Developmental outcome was evaluated at two weeks and again at nine months after the expected date of birth. At the two-week evaluation infants in the developmentally oriented group had better scores on measures of autonomic, motor-system and self-regulation. At nine months, they also had better scores on the Mental Developmental Index and the Psychomotor Developmental Index., Objective.--To investigate the effectiveness of individualized developmental care in reducing medical and neurodevelopmental sequelae for very low-birthweight infants. Design.--Randomized controlled trial. Setting.--Newborn intensive care unit. Patients.--Thirty-eight singleton preterm infants, free of known congenital abnormalities, weighing less than 1250 g, born before 30 weeks' gestation, mechanically ventilated within 3 hours of delivery and for more than 24 hours in the first 48 hours, randomly assigned to a control or an experimental group. Intervention.--Caregiving by nurses specifically trained in individualized developmental care; observation and documentation of the infants' behavior within 12 hours of admission, and subsequently every 10th day; developmental care recommendations and ongoing clinical support for the nurses and parents based on regular observation of the infant by developmental specialists; and the availability of special caregiving accessories. Main Outcome Measures.--Medical outcome, including average daily weight gain; number of days the infant required mechanical ventilation, oxygen, gavage tube feeding, and hospitalization; severity of retinopathy of prematurity, bronchopulmonary dysplasia, pneumothorax, and intraventricular hemorrhage; pediatric complications; age at discharge; and hospital charges. Neurodevelopmental outcome, including Assessment of Preterm Infants' Behavior scale and quantified electroencephalography (2 weeks after due date); and Bayley Scales of Infant Development and Kangaroo Box Paradigm (9 months after due date). Results.--The infants in the experimental group had a significantly shorter duration of mechanical ventilation and supplemental oxygen support; earlier oral feeding; reduced incidence of intraventricular hemorrhage, pneumothorax, and severe bronchopulmonary dysplasia; improved daily weight gain; shorter hospital stays; younger ages at hospital discharge; and reduced hospital charges compared with the infants in the control group. At 2 weeks after their due dates, these infants also showed improved autonomic regulation, motor system functioning, self-regulatory abilities, and visual evoked potential measures; and at 9 months, they had improved Bayley Mental and Psychomotor Developmental Index scores, as well as Kangaroo Box Paradigm scores. Conclusion.--Very low-birth-weight preterm infants may benefit from individualized developmental care in the neonatal intensive care unit in terms of medical and neurodevelopmental outcome. (JAMA. 1994;272:853-858)

Abstract Background Language comprehension requires decoding of complex, rapidly changing speech streams. Detecting changes of frequency modulation (FM) within speech is hypothesized as essential for accurate phoneme detection, and thus, for spoken word comprehension. Despite past demonstration of FM auditory evoked response (FMAER) utility in language disorder investigations, it is seldom utilized clinically. This report's purpose is to facilitate clinical use by explaining analytic pitfalls, demonstrating sites of cortical origin, and illustrating potential utility. Results FMAERs collected from children with language disorders, including Developmental Dysphasia, Landau-Kleffner syndrome (LKS), and autism spectrum disorder (ASD) and also normal controls - utilizing multi-channel reference-free recordings assisted by discrete source analysis - provided demonstratrions of cortical origin and examples of clinical utility. Recordings from inpatient epileptics with indwelling cortical electrodes provided direct assessment of FMAER origin. The FMAER is shown to normally arise from bilateral posterior superior temporal gyri and immediate temporal lobe surround. Childhood language disorders associated with prominent receptive deficits demonstrate absent left or bilateral FMAER temporal lobe responses. When receptive language is spared, the FMAER may remain present bilaterally. Analyses based upon mastoid or ear reference electrodes are shown to result in erroneous conclusions. Serial FMAER studies may dynamically track status of underlying language processing in LKS. FMAERs in ASD with language impairment may be normal or abnormal. Cortical FMAERs can locate language cortex when conventional cortical stimulation does not. Conclusion The FMAER measures the processing by the superior temporal gyri and adjacent cortex of rapid frequency modulation within an auditory stream. Clinical disorders associated with receptive deficits are shown to demonstrate absent left or bilateral responses. Serial FMAERs may be useful for tracking language change in LKS. Cortical FMAERs may augment invasive cortical language testing in epilepsy surgical patients. The FMAER may be normal in ASD and other language disorders when pathology spares the superior temporal gyrus and surround but presumably involves other brain regions. Ear/mastoid reference electrodes should be avoided and multichannel, reference free recordings utilized. Source analysis may assist in better understanding of complex FMAER findings.

Abstract Background The autism rate has recently increased to 1 in 100 children. Genetic studies demonstrate poorly understood complexity. Environmental factors apparently also play a role. Magnetic resonance imaging (MRI) studies demonstrate increased brain sizes and altered connectivity. Electroencephalogram (EEG) coherence studies confirm connectivity changes. However, genetic-, MRI- and/or EEG-based diagnostic tests are not yet available. The varied study results likely reflect methodological and population differences, small samples and, for EEG, lack of attention to group-specific artifact. Methods Of the 1,304 subjects who participated in this study, with ages ranging from 1 to 18 years old and assessed with comparable EEG studies, 463 children were diagnosed with autism spectrum disorder (ASD); 571 children were neuro-typical controls (C). After artifact management, principal components analysis (PCA) identified EEG spectral coherence factors with corresponding loading patterns. The 2- to 12-year-old subsample consisted of 430 ASD- and 554 C-group subjects (n = 984). Discriminant function analysis (DFA) determined the spectral coherence factors' discrimination success for the two groups. Loading patterns on the DFA-selected coherence factors described ASD-specific coherence differences when compared to controls. Results Total sample PCA of coherence data identified 40 factors which explained 50.8% of the total population variance. For the 2- to 12-year-olds, the 40 factors showed highly significant group differences (P < 0.0001). Ten randomly generated split half replications demonstrated high-average classification success (C, 88.5%; ASD, 86.0%). Still higher success was obtained in the more restricted age sub-samples using the jackknifing technique: 2- to 4-year-olds (C, 90.6%; ASD, 98.1%); 4- to 6-year-olds (C, 90.9%; ASD 99.1%); and 6- to 12-year-olds (C, 98.7%; ASD, 93.9%). Coherence loadings demonstrated reduced short-distance and reduced, as well as increased, long-distance coherences for the ASD-groups, when compared to the controls. Average spectral loading per factor was wide (10.1 Hz). Conclusions Classification success suggests a stable coherence loading pattern that differentiates ASD- from C-group subjects. This might constitute an EEG coherence-based phenotype of childhood autism. The predominantly reduced short-distance coherences may indicate poor local network function. The increased long-distance coherences may represent compensatory processes or reduced neural pruning. The wide average spectral range of factor loadings may suggest over-damped neural networks.