Behaviour of 4- to 5-year-old nondisabled ELBW children: Outcomes following group-based physiotherapy intervention.

BACKGROUND: Extreme prematurity or extremely low birth weight (ELBW) can adversely affect behaviour. Nondisabled ELBW children are at risk of behavioural problems, which may become a particular concern after commencement of formal education. This study explored the frequency of behavioural and emotional problems amongst nondisabled ELBW children at 4 to 5 years of age and whether intervention had a positive influence on behaviour. The relationship between behaviour, gender, and other areas of performance at 5 years was explored. METHODS: Fifty 4-year-old children (born <28 weeks gestation or birth weight <1,000 g) with minimal/mild motor impairment were randomly allocated to intervention (n = 24) or standard care (n = 26). Intervention was 6 group-based physiotherapy weekly sessions and home programme. Standard care was best practice advice. The Child Behavior Checklist (CBCL) for preschool children was completed at baseline and at 1-year post-baseline. Other measures at follow-up included Movement Assessment Battery for Children Second Edition, Beery Visual-Motor Integration Test 5th Edition, and Peabody Picture Vocabulary Test 4th Edition. RESULTS: The whole cohort improved on CBCL total problems score between baseline (mean 50.0, SD 11.1) and 1-year follow-up (mean 45.2, SD 10.3), p = .004. There were no significant differences between groups over time on CBCL internalizing, externalizing, or total problems scores. The intervention group showed a mean difference in total problems score of -3.8 (CI [1.5, 9.1]) between times, with standard care group values being -4.4 (CI [1.6, 7.1]). Males had higher total problems scores than females (p = .026), although still performed within the "normal" range. CBCL scores did not correlate with other scores. CONCLUSIONS: The behaviour of nondisabled ELBW children was within the "normal" range at 4 to 5 years, and both intervention and standard care may have contributed to improved behavioural outcomes. Behaviour was not related to performance in other developmental domains.

Hemodynamic and ventilatory effects of manual respiratory physiotherapy techniques of chest clapping, vibration, and shaking in an animal model.

Chest clapping, vibration, and shaking were studied in 10 physiotherapists who applied these techniques on an anesthetized animal model. Hemodynamic variables (such as heart rate, blood pressure, pulmonary artery pressure, and right atrial pressure) were measured during the application of these techniques to verify claims of adverse events. In addition, expired tidal volume and peak expiratory flow rate were measured to ascertain effects of these techniques. Physiotherapists in this study applied chest clapping at a rate of 6.2 +/- 0.9 Hz, vibration at 10.5 +/- 2.3 Hz, and shaking at 6.2 +/- 2.3 Hz. With the use of these rates, esophageal pressure swings of 8.8 +/- 5.0, 0.7 +/- 0.3, and 1.4 +/- 0.7 mmHg resulted from clapping, vibration, and shaking respectively. Variability in rates and "forces" generated by these techniques was <20% in average coefficients of variation. In addition, clinical experience accounted for 76% of the variance in vibration rate (P = 0.001). Cardiopulmonary physiotherapy experience and layers of towel used explained approximately 79% of the variance in clapping force (P = 0.004), whereas age and clinical experience explained >80% of variance in shaking force (P = 0.003). Application of these techniques by physiotherapists was found to have no significant effects on hemodynamic and most ventilatory variables in this study. From this study, we conclude that chest clapping, vibration, and shaking 1). can be consistently performed by physiotherapists; 2). are significantly related to physiotherapists' characteristics, particularly clinical experience; and 3). caused no significant hemodynamic effects.

A prospective study of laboratory and clinical measures of postural stability to predict community-dwelling fallers.

BACKGROUND: The identification of specific risk factors for falls in community-dwelling elderly persons is required to detect early changes and permit a preventative approach to management. This study determines the ability of various laboratory measures and clinical tests of postural stability to prospectively predict fallers in community-dwelling elderly women. METHODS: One hundred elderly women (65-86 years, mean age 73 +/- 5 years) performed a reaction-time step task, a limits of stability, and a quiet stance balance task. Postural muscle timing and movement speed were recorded during the step task. Center of pressure (COP) motion was recorded in quiet stance and at the limits of stability. Four common clinical balance tests were performed, and balance confidence, medical and activity history questionnaires were completed. Subjects were followed up regularly for a 6-month period following testing to determine the frequency and characteristics of any falls that occurred. Predictive capabilities of the balance measures to determine fallers were determined through logistic regression models. RESULTS: The clinical balance tests investigated were not able to predict fallers in this community-dwelling elderly population. A combination of variables from the laboratory tasks provided the best overall prediction rate (77%) of fallers (sensitivity 51%) and nonfallers (specificity 91%) from laboratory measures. Of these, step movement time and gluteus medius onset times were the factors best able to predict fallers. Alone, measures of COP motion in quiet stance and at the limits of stability had a poor ability to predict fallers, although they could correctly identify most nonfallers. Prediction was not significantly improved when clinical balance test results were added to the most predictive laboratory measures. CONCLUSIONS: Not all older adults with a reduction in balance ability reported a fall over a 6-month period. Of those who did, a combination of measures reflective of different aspects of mediolateral postural stability during a rapid step task, quiet stance, and movement to the limits of stability were best able to predict faller status, with nonfallers better predicted than fallers. These results emphasize the importance of the multifactorial nature of falls in the community-dwelling elderly population in that the clinical and laboratory measures did not predict a high proportion of fallers.

The influence of growth on development outcome in extremely low birthweight infants at 2 years of age.

OBJECTIVE: To determine if weight < 3rd and < 10th centile at 2 years in extremely low birthweight (ELBW) infants is associated with problems of development and motor skills, and whether this association is explained by perinatal risk status. METHODOLOGY: One hundred and ninety-eight of 226 (88%) surviving ELBW infants born between January 1987 and December 1992 were assessed at 2 years corrected age. Children were classified as being at low perinatal risk (n = 128) or high perinatal risk (n = 70) for adverse developmental outcome based on perinatal risk factors. Weight at 2 years was classified as < 3rd, 3rd-9th or > or = 10th centile for age and gender. Development was assessed using the Griffiths Mental Developmental Scales and motor skills using the Neurosensory Motor Developmental Assessment (NSMDA). RESULTS: For the total study group weight centile was strongly related to General Quotient (GQ) and motor abilities. For children < 3rd percentile (n = 48) mean (GQ) was 90.4 (SD, 15.9), for children between the 3rd-9th percentile (n = 49) 91.5 (SD, 17.9), and for children > or = 10th percentile (n = 99) mean GQ was 99.8 (SD, 8.6). The association with mean GQ and NSMDA category occurred for the high-risk subgroup and became non-significant in the low-risk subgroup if neurologically abnormal children were excluded. Other perinatal risk factors, exposure to breast milk, level of maternal education, marital status and history of feeding problems or infections over the 2 years did not confound this association. CONCLUSION: Low weight percentile at 2 years was related to adverse developmental outcome in ELBW infants at high perinatal risk or with neurological impairment, though minimal association was present for neurologically normal infants at low perinatal risk.

A longitudinal physical profile assessment of skeletal muscle manifestations in myotonic dystrophy.

OBJECTIVES: To develop an assessment that describes the skeletal muscle manifestations in myotonic dystrophy subjects and then use it to quantify the presentation of skeletal muscle disability and to show change over time. DESIGN: A quantified skeletal muscle assessment was developed and applied three times over a two-year period at intervals around 12 months. Thirty-six subjects with myotonic dystrophy and 20 subjects without neuromuscular disability were evaluated. The assessment comprised manual muscle testing of five pairs of muscles, measuring neck flexor strength with a strain gauge, respiratory function tests, power and lateral pinch grip strength, all tests of impairment. Assessment of the ability to move from sitting to standing and fasten buttons tested disability. RESULTS: Results from subjects with myotonic dystrophy were compared to the normal data. The subjects with myotonic dystrophy were significantly weaker in proximal upper limb muscles, quadriceps, tibialis anterior muscles and neck flexor muscles as well as power and lateral pinch grips. There was also significant reduction in forced expiratory volume at one second (FEV1) and forced vital capacity (FVC). Significant disability was seen in the myotonics in moving from sitting to standing and in fastening buttons. Over the two-year study period proximal upper limb and lower limb muscle strength, FVC and sit-to-stand ability declined significantly. Power grip declined but lateral pinch grip and FEV1 improved significantly. Button fastening ability improved significantly. CONCLUSION: The test developed was shown to be reliable and sensitive to the change in skeletal muscle manifestations in subjects with myotonic dystrophy who were shown to be significantly weaker than normal subjects.

Maternal hypertension and neurodevelopmental outcome in very preterm infants.

AIM: To determine the outcome of preterm infants born to mothers with hypertension during pregnancy, and preterm controls. METHODS: 107 infants of 24-32 weeks gestation, born to hypertensive mothers, and 107 controls matched for gestational age, sex, and multiple pregnancy, born to normotensive mothers, were prospectively enrolled over 2 years. Information on maternal complications and medication was obtained and neonatal mortality and morbidities recorded. Survivors were followed up to at least 2 years, corrected for prematurity. RESULTS: One third of the hypertensive mothers were treated with antihypertensive drugs, while 18% received convulsion prophylaxis with phenytoin. Magnesium sulphate was not prescribed. Both groups had a mean gestational age of 29.9 weeks, with the study infants having a significantly lower birthweight than the controls. Four study and three control infants died in the neonatal period. Cerebral palsy was not diagnosed in any infant of a hypertensive mother compared with five of the controls. The mean general quotient for the two groups was very similar and no difference in the incidence of minor neuromotor developmental problems was shown. CONCLUSIONS: Maternal hypertension seems to protect against cerebral palsy in preterm infants without increasing the risk of cognitive impairment. This was independent of the use of maternally administered magnesium sulphate.

Characteristics at four months follow-up of infants born small for gestational age: a controlled study.

This prospective study compared 65 small-for-gestational-age (SGA) (birth weight < 3rd centile) and 71 control infants at a corrected age of 4 months. It was hypothesised that differences would exist in growth, development, temperament and minor neurological signs and that these would be predicted by type (proportional/disproportional) of growth restriction at birth and maternal mood disturbance at birth or at 4 months. Infants had a Griffith's developmental test and neuromotor assessment. Maternal mood and infant temperament were surveyed. Few differences were found between SGA and control infants. SGA infants showed catch-up growth with 63% being above the third percentile and 43% being above the tenth percentile for weight. SGA infants had lower Griffith's GQ scores (97 vs. 102, P = 0.02) and they were rated in temperament as more manageable than controls. There were no differences in subtle neuromotor signs. Neither type of SGA nor maternal mood disturbance at birth had prognostic significance for infant catch up growth, neuromotor scores, or temperament though level of maternal stress and anxiety at 4 months were related to lower GQ scores in SGA infants.

Survival and neonatal and neurodevelopmental outcome of 24-29 week gestation infants according to primary cause of preterm delivery.

A total of 189 infants of 24-29 weeks' gestation were born in a regional perinatal centre during a 2-year period. They were divided into groups according to the primary cause of preterm delivery: antepartum haemorrhage (n = 37, 20%), preeclampsia (n = 27), 14%), preterm premature rupture of membranes (n = 64, 34%), preterm labour (n = 27, 14%), chorioamnionitis (n = 16, 8%), other complications (n = 18, 10%). The perinatal mortality rate (PMR) was 286/1,000 of whom 44% were stillbirths. The 'other complication' group had the highest PMR due to a large number of intrauterine deaths, with no differences in neonatal mortality between the groups. Preeclampsia was associated with an increased risk of necrotizing enterocolitis and chorioamnionitis was associated with an increased risk of periventricular haemorrhage. Follow-up to at least 2 years was performed in 122 (97%) of survivors. Cerebral palsy occurred in 7%, while 18% had neurodevelopmental disability. No relationship was found between primary cause of preterm delivery and outcome. This information should be of value in counselling parents when preterm delivery is imminent.

School performance of ELBW children: a controlled study.

This paper examines the prevalence of learning difficulty in reading, spelling, mathematics and writing and the prevalence of attention deficit disorder (ADD) in extremely low-birthweight (ELBW) children at school compared to their peers. Parents of 87 eligible ELBW children completed an educational questionnaire and questionnaire for ADD. Teachers of the ELBW children completed a detailed educational and ADD questionnaire for the study child and two control children in the same class, matched for age and nearest in birth date to the study child. Parents reported that 4% of the ELBW children born between 1977 and 1986 were in a special education unit, 46% received remedial help and 21% repeated a grade. Teacher assessment of six aspects of reading and spelling and five aspects of mathematics and writing skills indicated that the ELBW children experienced marked problems in all areas compared to control children and were approximately 3 times more likely to be delayed by more than a year in all areas. Prevalence of ADD was not increased in the ELBW children compared to the control group, though males in both groups had a higher prevalence of symptoms. Early intervention and special education resources must be available for ELBW children attending school.

Prevalence and aetiology of neurological impairment in extremely low birthweight infants.

OBJECTIVE: To determine the prevalence and perinatal predictors of cerebral palsy, intellectual impairment, visual impairment and deafness in a cohort of extremely low birthweight (ELBW) infants at two years of age. METHODOLOGY: The study population comprised 199 of the 224 (89%) ELBW infants managed at the Mater's Mothers Hospital, Brisbane, between July 1977 and February 1990 and who survived to two years. The prevalence of cerebral palsy, intellectual impairment, blindness and deafness was measured by clinical,psychometric and audiological assessment and the association with 24 risk factors examined. RESULTS: Cerebral palsy occurred in 20 children (10%). Risk of cerebral palsy was associated with ventricular dilatation, intraventricular haemorrhage, necrotizing enterocolitis and multiple birth, though only ventricular dilatation (OR 4.41; 95% CI 1.32-14.8) remained significant in the adjusted analysis. Intellectual impairment occurred in 20 children (10%) and was independently associated with ventricular dilatation (OR 15.0; 95% CI 2.2-102.8), ventilation F(i)(2) > 80% (OR 3.4; 95% CI 1.01-11.5), vaginal delivery (OR 3.5; 95% Cl 1.09-11.4) and male sex (OR 6.1; 95% Cl 1.67-22.3). No perinatal predictor was statistically associated with risk of deafness. Retinopathy of prematurity (OR 36.9; 95% Cl 2.8-495.5) was associated with risk of later visual impairment. CONCLUSIONS: Intellectual impairment was associated with a broad range of perinatal variables. Cerebral palsy was associated with fewer variables, all of which were also associated with intellectual impairment. Neurologic injury was associated with male sex and multiple birth, which are not biological insults themselves, but may be markers of susceptibility to injury.

Neurodevelopmental outcome of preterm infants with bronchopulmonary dysplasia.

The neurodevelopmental outcome of 78 infants with bronchopulmonary dysplasia (BPD) was compared with that of 78 control infants matched for birthweight. To determine the effect of the severity of BPD, 62 infants requiring oxygen at 36 weeks' postmenstrual age (sBPD) were compared with their matched controls. Infants were followed up to 2 years of age, corrected for prematurity, and were classified for neurological impairment, developmental delay, and neurodevelopmental disability. Seventy six (98%) BPD infants and 71 (91%) controls had follow up data available to two years. Neurological impairment, developmental delay, and neurodevelopmental disability occurred more frequently in infants with BPD than in controls but this was not significant. For infants with sBPD, the increased incidence of neurological impairment and definite developmental delay was not significant when compared with the controls, though neurodevelopmental disability occurred more frequently (odds ratio (OR) 3.6: 95% confidence intervals (CI) 1.1-11.8). Predictors of disability in infants with sBPD included periventricular haemorrhage (OR 19.4: 95% CI 4.3-86.6), ventricular dilatation (OR 12.8: 95% CI 2.9-57.3), and sepsis (OR 5.0: 95% CI 1.3-19.4). Adjusting for the presence of these factors, the association between BPD and disability was no longer apparent (OR 0.9: 95% CI 0.2-3.6). The findings suggest that BPD is not independently associated with adverse neurodevelopmental outcome.

Changing patterns of survival and outcome at 4 years of children who weighted 500-999 g at birth.

OBJECTIVE: To evaluate the impact of changing perinatal practices on survival rates and 4 year neurodevelopmental outcome for infants of birthweight 500-999 g. METHODOLOGY: The study was a tertiary hospital-based prospective cohort study that compared survival, impairment and handicap rates between two eras, July 1977 to December 1982 (era 1) and January 1983 to June 1988 (era 2). All 348 live, inborn infants and 49 outborn infants of birthweight 500-999 g were prospectively enrolled in a study of survival and outcome. Rates of survival, neurodevelopmental impairment and functional handicap at 4 years were compared between eras. Perinatal risk factors for handicap were also compared between eras. RESULTS: Four year survival rates for inborn infants 500-999 g improved from 32.6% in era 1 to 49.2% in era 2 (OR 2.1, 95% CI 1.26-3.48) but for outborn infants the improvement between 31.8% and 53.6% was not significant. There were significant improvements in survival for inborn infants in birthweights 800-899 g and 900-999 g between study periods. The rates of functional handicap between the first and second eras (mild 10 vs 7%; severe or multiply severe 14 vs 16%) were not significantly different. Although the rate of cerebral palsy increased from 0 to 12% (P < 0.01) other rates of impairment such as blindness 0 vs 3%, deafness 2 vs 2% and developmental delay 12 vs 11% did not change. The chance of a survivor being free of handicap remained unchanged at 78% and 76% for the two eras, respectively. Although the absolute number of intact survivors more than doubled (41 vs 83) so too did the number of severe or multiply severe handicapped survivors (7 vs 17). Multivariate logistic regression analysis for the entire study cohort revealed male gender, multiple birth, prolonged mechanical ventilation and cerebral ventricular dilatation but not birthweight or gestational age to be independently associated with severe or multiply severe handicap. CONCLUSIONS: The advances in neonatal intensive care for extremely low birthweight infants between July 1977 and December 1982 and January 1983-June 1988 resulted in an increased number of non-disabled survivors but had no impact on incidence of severe disability. The application of prediction of mortality or severe handicap to clinical practice has the potential to reduce the proportion and absolute number of severely handicapped survivors.

Reduction of craniofacial and palatal narrowing in very low birthweight infants.

Many infants born preterm have positional moulding of the head and palate. This study investigates whether specially designed, foam pressure dispersing pads (PDP) worn throughout the neonatal hospital course, were not only effective in reducing craniofacial flattening, but also in lessening palatal narrowing in very low birthweight (VLBW) infants. The study was conducted in two phases. Twenty-three consecutively born VLBW infants were randomly selected to act as a comparative group. The next 31 VLBW infants born comprised the intervention group, and wore PDP during hospitalization. The two groups were similar in birthweight and gestational age. The groups were compared for changes in craniofacial and palatal parameters at three time intervals during hospitalization. Results indicated a significant increase in growth of craniofacial width, palatal width and palatal area of infants wearing PDP compared to those infants not wearing them. These findings suggest that craniofacial and palatal narrowing observed in VLBW infants may be reduced by the wearing of PDP during hospitalization.

Perinatal hypoxic-ischaemic brain injury: prediction of outcome.

Twenty-six term babies with hypoxic-ischaemic brain injury were studied during the neonatal period to evaluate the prediction of outcome to at least one year of age by means of ultrasonography, CT scanning and Doppler ultrasound assessment of cerebral palsy blood flow velocity (CBFV). Adverse outcome was defined as the occurrence of cerebral palsy, developmental delay or death. At follow-up, 17 infants had an adverse outcome (seven died, 10 had disability); the remainder had no detectable impairment. Abnormalities on cranial ultrasound were not, but generalised decreased tissue density on CT scan was, associated with adverse outcome. Abnormal mean CBFV in the middle cerebral artery had no association with outcome, but abnormal mean CBFV in the anterior cerebral artery and a low resistance index in both arteries were significantly associated with adverse outcome. Such information may be used for appropriate counselling of parents of asphyxiated infants.

Palatal measurements of prematurely born, very low birth weight infants: comparison of three methods.

To enable investigation of palatal changes in infants who are prematurely born, it is necessary to first establish a reliable method of measurement of these tiny edentulous palates. This study compared the Olivetti-Inspector machine, Vernier calipers, and stereophotogrammetry for this purpose. Measurements were taken of 12 palatal casts of four infants at prescribed time intervals during the neonatal period. In each of the three methods, measurements were recorded as variables generated in the X and Z axes of the Cartesian scale in relation to three specified points along the Y axis. The results revealed that all methods were comparable, but the Vernier calipers differed significantly from the other two methods in height measurements, (p < 0.001). It was also found that both the Olivetti-Inspector machine and the Vernier calipers consistently underestimated the width, compared with Olivetti-Inspector machine, (p < 0.05). Stereophotogrammetry was found to be the most consistent method of measuring the configuration of preterm infant palates.

The motor performance of preschool-aged children after surgery for congenital heart disease.

This study compared the motor performance of preschool-aged children who had undergone surgery for congenital heart disease with that of a group of children matched for age, sex, preschool experience, racial and socio-economic background. Analysis of the results indicated that the performances of the children with congenital heart disease were significantly immature compared to the performances of the control children on the total assessment and in the areas of gross motor, muscle strength, fine motor, tone and postural reactions. Sex, age at first surgical intervention and presence of a cyanotic heart defect did not influence the performances of the study group children. Age at assessment and socio-economic background were found to influence motor performances. The need for physiotherapists to be involved in the follow-up of children with congenital heart disease is supported.

Early identification of cerebral palsy in high risk infants.

This study of high risk infants aimed to identify which signs at the corrected ages of 1, 4 and 8 months were important for distinguishing those infants who later developed hypertonic cerebral palsy (CP). From a total cohort of 450 infants (350 of birthweight less than 1500 g and 100 of birthweight greater than 1500 g), 26 infants were later diagnosed as having CP and formed the study group. A control group of 26 infants from the same initial cohort who did not develop CP was matched to the study group. Both groups were followed for a minimum of 2 years. At each assessment (1, 4, 8, 24 months corrected age), all children were assessed using a standard medical examination and a detailed neurosensorimotor developmental scale that evaluated neurological signs, motor attainments, primitive reflexes and postural reactions. Each test response was graded as normal, suspect or abnormal and the results for the two groups were compared. Assessment at 1 month failed to identify a number of the CP infants whereas at 4 months there was some overidentification. At 8 months, assessment was highly predictive of cerebral palsy. Individual signs of abnormality were found to be of limited value but the presence of three or more abnormal signs at 8 months was highly predictive of CP.

The Neuro-sensory Motor Developmental Assessment Part 1: Development and Administration of the Test.

The Neuro-sensory Motor Developmental Assessment (NSMDA) has been developed to meet the need for a progressive developmental assessment of infants and children. In this study a cohort of 148 preterm infants was assessed at 1, 4, 8, 12, and 24 months adjusted age. The results were used to classify the subjects as having normal, suspect or abnormal developmental status. The scores for each time were correlated with outcome scores at 24 months. Part One of this paper includes a description of the development and administration of the NSMDA. Longitudinal and cross correlations of scores were analysed and shown to be highly significant over the first two years of testing, thereby establishing the basis for validity and predictability of the NSMDA.

The Neuro-Sensory Motor Developmental Assessment Part II: Predictive and Concurrent Validity.

The Neuro-sensory Motor Developmental Assessment (NSMDA) has been developed to meet the need for a progressive evaluation of infants and children. The content and administration of the NSMDA has been addressed in Part One of this paper. In this study the NSMDA was used to assess a cohort of 148 preterm infants at 1, 4, 8, 12, and 24 months. Results recorded at each assessment were compared with developmental outcome at 24 months. This paper provides statistical evidence of the NSMDA's validity. Verification in terms of predictive validity (sensitivity/specificity), and concurrent validity is described. Although early NSMDA scores were significantly correlated with outcome at two years, 8 months was found to be the optimal age for accurately discriminating between children who demonstrated normal or abnormal developmental status.

Apnoea in very low birthweight infants: outcome at 2 years.

Follow-up data to 2 years are reported for 164 of an initial cohort of 172 consecutively, surviving very low birth-weight infants. The 13 infants who suffered apnoeic episodes at home were not predicted at discharge from hospital. The mean (s.d.) general developmental quotient at 2 years for the total group was 97.3 (12.0), compared with 99.0 (10.2) for the 72 infants who had nil-mild apnoea in the newborn period and 96.0 (13.4) for the 92 infants with moderate-severe apnoea (P less than 0.1). All six infants with general quotients less than 76 had sustained moderate-severe apnoea (P less than 0.05). Multivariate analysis to assess the influence of confounding variables showed that the presence of chronic lung disease decreased the general quotient by 4.0 units, birthweight less than 1000 g 3.3 units, mechanical ventilation 2.2 units and moderate-severe apnoea only 0.1 unit. Moderate-severe apnoea occurred in six of eight babies with neurological handicap and all eight with sensory handicaps (P less than 0.01). Overall, of the 12 (7.3%) handicapped children, two had no apnoea and 10 moderate-severe apnoea (P = 0.07). Moderate or severe apnoea occurred in 58% of very low birthweight infants and was associated with the smallest and sickest infants who had the most handicaps at 2 years. However, when correction for birthweight less than 1000 g, mechanical ventilation and chronic lung disease is made, apnoea per se, as it was detected and managed between 1978-80, had no additional deleterious effect on average intellectual performance though it may have been an important causative factor in functional handicap.