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.

Prevalence of incontinence and incontinence-specific quality of life impairment in women with cystic fibrosis.

AIMS: Cystic fibrosis (CF) is the commonest autosomal recessive disorder in Caucasians. With advancing medical technology, the life expectancy has more than double in the last twenty years. This has led to new unforeseen health problems like urinary incontinence. The aim was to establish the prevalence, symptomatic typology, and quality of life impact of incontinence in a population of women with CF. METHODS: Women were recruited from two London tertiary referral centres for CF. They were asked to fill in a self- completed anonymous King's Health Questionnaire (KHQ) for assessment of symptoms and quality of life Impairment. Their age was also noted. Descriptive statistics are reported. Correlation was assessed using Pearson's Product Moment Correlation Coefficient (r). RESULTS: One hundred and forty six women were approached for enrolment. 98(67%) consented to take part in study. Their mean age was 28. Seventy three (74%) reported symptoms of urinary incontinence, which in all cases was perceived as stress urinary incontinence. Of these 44(60%) reported mild stress incontinence, 16(22%) moderate stress incontinence and 13(18%) severe stress incontinence. Continent and incontinent women perceived their general health to be similarly poor (mean score 40 vs 44 points). Strong positive correiations were found between age and stress urinary incontinence severity (r=0.742; P <0.001) and between age and total King's Health Questionnaire score (r=0.828; P <0.001). CONCLUSIONS: Women with CF have a higher prevalence of stress urinary incontinence than the general population, with both the prevalence and associated quality of life impairment increasing with age.

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.

Non-anaemic iron deficiency identified by ZPP test in extremely premature infants: prevalence, dietary risk factors, and association with neurodevelopmental problems.

INTRODUCTION: The aims of this study were to determine, in a cohort of extremely premature infants, the prevalence of iron deficiency identified by zinc protoporphyrin/heme ratio (ZPP) testing, and its association with neurodevelopmental problems and dietary risk factors for iron deficiency. METHODS: Infants of less than 29 weeks' gestation or less than 1000 g birth weight were studied prospectively at a multidisciplinary follow-up clinic. Assessments were made at a corrected age of either 12 months (n=72) or 2 years (n=69). Physical examination, Griffiths Developmental Scale, and neurosensory-motor assessment were administered, information on diet and behaviour was obtained by questionnaire, and a fingerprick ZPP ratio was performed to identify iron deficiency. RESULTS: 18.4% of infants had positive ZPP tests. There was no significant association between a positive ZPP test result and dietary risk factors, or symptoms of lethargy, irritability or poor attention. In children without cerebral palsy, there was no difference on Griffiths scores or neurosensory-motor assessment between ZPP-positive and ZPP-negative groups. The diagnosis of cerebral palsy (n=12) was significantly associated with both a positive ZPP test and a lower Griffiths general quotient (GQ) score. CONCLUSIONS: Iron deficiency occurs commonly in extremely low birth weight (ELBW) children in early childhood, and is not predicted by dietary risk factors. The prevalence of iron deficiency is increased in ELBW children with cerebral palsy. Non-anaemic iron deficiency (NAID) does not impair development or significantly affect behaviour of ELBW subjects who do not have cerebral palsy.

The measurement of the medial longitudinal arch in children.

Both feet of two hundred and seventy two children aged between five years six months and ten years and eleven months were studied using a footprint technique called the arch index (Al), and the vertical height of the navicular (NH) as non invasive techniques of objective measures of the medial longitudinal arch (MLA). In addition to age the study investigated the influence of gender, limb dominance, and body weight. The study found the existence of a relationship between the two measures of the MLA. There was no significant difference in NH measures between males and females and body weight did not affect the NH. The NH changed with age, suggesting it provides a useful, easily obtained clinical measure. The Al measures were slightly more reliable than the NH but showed less change with age.

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 effect on sound generation of varying both gas flow rate and the viscosity of sputum-like gel in a simple tubular model.

Gas flows of 2, 3, and 4 L/min were directed through a sputum-like gel with viscosities of 100, 150, and 200 P and placed in a tube similar in diameter to a human segmental bronchus (4 mm), which was immersed in a bath of water. The sound produced by gas flow through the gel was recorded with a hydrophone. Sound data were subjected to time-expanded waveforms and fast Fourier transform (FFT) analysis. This study demonstrated that the number of crackles generated was directly related to the flow rate and inversely related to gel viscosity. The initial deflection width (IDW), two-cycle duration (2 CD), and peak-to-peak amplitude of crackles were significantly affected by the gas flow rate but not the viscosity of the gel. A lower gas flow rate generated crackles with longer IDW and 2 CD, but higher gas flow rates generated crackles with higher amplitude. Peak sound intensity measured from FFT increased as flow rate increased but decreased as the viscosity of the gel increased. At low gas flows, no gel-induced crackle sound was generated within the data capture window when the most viscous gel was examined. A digital video image of gas flow through the gel was captured, and this confirmed the absence of bubbles or slug formation at low flows through 200 P gel during the 3 seconds of data acquisition. This study describes some characteristics of crackles generated from different combinations of gas flow and gel viscosity and suggests that "coarse crackles" results from the explosion of gas bubbles in pulmonary secretions. Health care practitioners should consider the combined effect of rate of inspiratory gas flow and sputum viscosity during auscultation of patients' lungs.

The influence of "sputum-like gel" viscosity on crackle characteristics in a mechanically ventilated porcine lung model.

This study investigated the influence of airway secretion viscosity on the characteristics of crackle sounds produced using a mechanically ventilated porcine lung model. Aqueous ultrasonic methylene blue stained gel solutions of viscosity 100, 150 and 200 P were prepared and instilled into 15 isolated, mechanically ventilated, porcine lungs immersed in water. Sound signals recorded by a hydrophone before and after instillation of gel were subjected to both fast Fourier transform and wave-form analysis. At the completion of sound recording, the main bronchi were dissected and the location of the stained gel was photographically recorded. Wave-form analysis demonstrated that expiratory phase crackle incidence and amplitude were both significantly higher than inspiratory phase data. This study demonstrates that crackle duration and amplitude are inversely related to gel viscosity and that electronic lung sound analysis can provide indirect evidence of sputum viscosity.

Lateral reach: a clinical measure of medio-lateral postural stability.

BACKGROUND AND PURPOSE: Medio-lateral postural instability has recently been identified as a risk factor for falls in the elderly community-dwelling population. However, few clinical tests involve challenges to stability limits in the medio-lateral direction. A lateral reach test was thus developed. Preliminary evaluation of the symmetry, accuracy, test-retest repeatability, and construct validity of the lateral reach test was undertaken to ensure its validity and repeatability prior to clinical application. METHOD: Sixty healthy older female subjects (aged 72.5 +/- 5 years) participated in this study which involved two tasks. The first was the clinical test: a maximal lateral reach to the right and left, recorded by a clinical measure (observation of hand excursion) and a laboratory measure (3D analysis of hand marker excursion). The second was the recording of centre of pressure (COP) stability limits in the lateral direction by use of a dual force platform system. Eighteen subjects returned for repeatability testing. RESULTS: No significant differences in the measures were found between the sides. Lateral reach as measured by the clinical measure was significantly (p < 0.05) correlated with both the laboratory measure of reach (r = 0.650) and with COP stability limits (r = 0.331). The clinical measure of reach was not significantly different (p > 0.01) from the laboratory measure. High test-retest repeatability (r > 0.94) was found for all measures. CONCLUSIONS: The clinical lateral reach test was found to be an accurate measure of lateral reach ability. As it was significantly correlated with COP excursion it was deemed a valid indicator of lateral stability limits. In addition, the lateral reach test had high test-retest repeatability and was symmetrical between the sides. These promising results support both it's use where a clinical indicator of medio-lateral postural stability is desired and further investigation of the lateral reach test in clinical populations.

Effect of positioning on recorded lung sound intensities in subjects without pulmonary dysfunction.

BACKGROUND AND PURPOSE: Physical therapists often use positioning to assist in the reexpansion of collapsed lung segments. An increase in lung sound intensity on auscultation is considered indicative of lung expansion. This study was designed to examine whether clinical interpretation of auscultatory findings is warranted. SUBJECTS: The subjects (5 male, 6 female) were young physical therapist students without pulmonary dysfunction (mean age=20.4 years, mean height=166.3 cm, mean weight=57.5 kg). Subjects with lung disease were excluded because pulmonary pathology is difficult to standardize. METHODS: Lung sounds electronically recorded over the posterior chest wall of subjects in sitting and side-lying positions were compared. Measures included peak intensity, frequency at maximum power, and median frequency. RESULTS: In the sitting position, inspiratory sounds recorded over the left posterior chest wall were louder than those recorded on the right side. In the side-lying positions, the sound intensity recorded from the dependent chest wall was louder than that recorded from the nondependent chest wall. In side-lying positions, the upper hemithorax is "nondependent," and the side in contact with the bed is "dependent." Sound intensities recorded over both posterior chest walls in the sitting position were louder than those recorded over the same lung area in the nondependent side-lying position. There was no difference in the sound intensity recorded between the sitting and dependent side-lying postures. CONCLUSION AND DISCUSSION: When comparative auscultation of the chest wall is used by physical therapists to assess the adequacy of pulmonary ventilation, patient posture and regional differences in breath sound intensity can influence clinical interpretation.

A study of repeated lateral pinch grip in myotonic dystrophy.

BACKGROUND AND PURPOSE: Subjects with myotonic dystrophy present with progressive muscle weakness, myotonia and fatigue. The aim of this study was to determine whether there was a difference in response to fatiguing exercise in myotonic dystrophy individuals compared to normal subjects. If no difference was found, a similar response to a physiotherapy exercise programme as seen in normal subjects might be expected. METHOD: Ten individuals with myotonic dystrophy were compared to eight normal subjects in their response to ten repetitions of maximal lateral pinch grip efforts each five seconds in duration and separated by a ten-second rest. The root mean square (RMS) values, initial median frequency (Fmed) and slope of the median frequencies were recorded by electromyography (EMG) for the first dorsal interosseus, flexor pollicis brevis, flexor digitorum profundus and extensor digitorum communis muscles in the forearm and hand. Simultaneously, the rate of grip development, rate of grip release and work done during each grip effort were recorded by dynamometer. The RMS values for all muscles from subjects with myotonic dystrophy increased over the ten repetitions. RESULTS: The initial Fmed for all myotonic dystrophy muscles was lower than for the normal subjects. The Fmed slopes for the first and last repetition showed no significant difference to the normal subjects. Rate of grip development was no different between groups over ten repetitions. Rate of grip release was slower and work done less for the individuals with myotonic dystrophy. CONCLUSION: Results suggest the main difference between muscles affected by myotonic dystrophy and normal ones was the smaller size of muscle fibres. The increase in rate of grip release that was found is supportive of the 'warm-up' phenomenon. This appears to indicate that muscles affected by myotonic dystrophy could benefit from standard physiotherapeutic exercise methods.

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.