Self-perceived health, functioning and well-being of very low birth weight infants at age 20 years.

OBJECTIVE: To examine the self-perceived health of very low birth weight (VLBW; <1.5 kg) infants during young adulthood. STUDY DESIGN: The population included 241 VLBW and 232 normal birth weight (NBW) controls who completed the Child Health and Illness Profile: Adolescent Edition (CHIP-AE) at 20 years of age. The CHIP-AE includes six domains: Satisfaction, Comfort, Resilience, Achievement, Risk Avoidance, and Disorders, and 13 profiles that characterize patterns of health. Results were compared between VLBW and NBW subjects adjusting for sex and sociodemographic status. RESULTS: VLBW subjects did not differ from NBW controls in the domains of Satisfaction or Comfort but reported less Resilience (effect size [ES] -0.19, P < .05), specifically in physical activity and family involvement. They reported better Achievement, specifically in work performance (ES 0.28, P < .05), more Risk Avoidance (ES 0.43, P < .001), and significantly more long-term medical, surgical, and psychosocial disorders. Similar proportions of VLBW and NBW subjects reported Excellent (15% vs 11%), Average (27% vs 34%), and Poor (12% vs 13%) profiles of health. CONCLUSIONS: VLBW subjects report similar health, well-being, and functioning compared with NBW controls and greater risk avoidance. However, we are concerned that their lesser resilience may prove detrimental to their future adult health.

Sleep estimation using wrist actigraphy in adolescents with and without sleep disordered breathing: a comparison of three data modes.

INTRODUCTION: Adolescence is a time of rapid changes in sleep habits and rising prevalence of sleepiness. The importance of measuring sleep in this population is increasingly recognized. In adults, measurements of sleep by actigraphy correlate well with sleep data from EEG recordings. Since actigraphy is increasingly utilized in adolescent sleep studies, more information is needed about reliability in this age group. This analysis investigated which actigraphy data mode is optimal for data collection in adolescents and explored the level of agreement between actigraphy and polysomnography (PSG) in population subgroups. METHODS: 181 adolescents aged 12-16 years were concurrently monitored with PSG and wrist actigraphy (measured in 3 data modes: Time Above Threshold [TAT], Zero Crossing Mode [ZCM], and Proportional Integration Mode [PIM]) to measure total sleep time (TST). RESULTS: The sample was 50% male, 55% African American, 9% with sleep disordered breathing (SDB; apnea-hypopnea index > or = 5). Intraclass correlation coefficients (ICC) for TST between actigraphy and PSG were low to moderate and were highest for TAT (0.41) compared to ZCM (0.32) and PIM (0.34). Subgroup analyses revealed that ICCs were higher among those without SDB (0.55) than those with SDB (0.00), and for girls (0.66) compared with boys (0.31). CONCLUSIONS: Results suggest that actigraphy provides a reasonably good estimate of TST in adolescents without SDB. Recognition of the variation in sleep estimates among different data collection modes, among population subgroups, and across the age spectrum, may be of fundamental importance in the interpretation of actigraphy data for sleep duration estimation.

Blood pressure among very low birth weight (<1.5 kg) young adults.

Our objective was to compare the blood pressure of 20-y-old very low birth weight (VLBW; <1.5 kg) individuals with that of normal birth weight (NBW) control individuals. The population included 195 VLBW (92 female and 103 male) and 208 NBW (107 female and 101 male) individuals who were born between 1977 and 1979. Independent effects of birth weight status (VLBW versus NBW) and within the VLBW cohort of intrauterine growth (birth weight z score) were examined via multiple regression analyses. VLBW individuals had a higher mean systolic blood pressure (SBP) than NBW control individuals (114 +/- 11 versus 112 +/- 13 mm Hg). SBP for VLBW female infants was 110 +/- 9 versus NBW 107 +/- 12 and for VLBW male individuals was 118 +/- 11 versus NBW 117 +/- 11 mm Hg. After adjustment for gender, race, and maternal education, the difference in SBP between VLBW and NBW individuals was 1.9 mm Hg but was 3.5 mm after also adjustment for later size (20-y weight and height z scores), which reflects catch-up growth. For female individuals, the difference in SBP between VLBW and NBW individuals was significant both unadjusted and adjusted for later size, whereas for male individuals, the difference was significant only after adjustment for later size. Intrauterine growth did not have a significant effect on SBP within the VLBW group, even after adjustment for later size. VLBW individuals, specifically female individuals, have a higher SBP than NBW control individuals. This is not explained by intrauterine growth failure.

Poor predictive validity of the Bayley Scales of Infant Development for cognitive function of extremely low birth weight children at school age.

OBJECTIVE: The Bayley Scales of Infant Development, Second Edition (BSID II) are commonly used to assess outcomes of extremely low birth weight (ELBW) infants. We sought to assess the predictive validity of the BSID II Mental Developmental Index (MDI) for cognitive function at school age. DESIGN/METHODS: Of 330 ELBW infants admitted in 1992-1995, 238 (72%) survived to the age of 8 years, of whom 200 (84%) were tested at both 20 months' corrected age (CA) and 8 years. Mean birth weight was 811 g, mean gestational age was 26.4 weeks, 41% were boys, and 60% were black. Measures included the BSID II at 20 months' CA and the Kaufman Assessment Battery for Children (KABC) Mental Processing Composite (MPC) at 8 years' postnatal age. BSID II MDI and MPC scores were compared and the predictive validity calculated for all 200 ELBW children and for the 154 ELBW neurosensory-intact subgroup. Predictors of stability or change in cognitive scores were examined via logistic regression adjusting for gender and sociodemographic status. RESULTS: For all ELBW children, the mean MDI was 75.6 +/- 16 versus a mean KABC of 87.8 +/- 19. For the neurosensory-intact subgroup, the mean MDI was 79.3 +/- 16 and the mean KABC was 92.3 +/- 15. Rates of cognitive impairment, defined as an MDI or KABC of <70, dropped from 39% at 20 months' CA to 16% at 8 years for the total ELBW population and from 29% to 7% for the neurosensory-intact subgroup. The positive predictive value of having an MPC of <70 given an MDI of <70 was 0.37 (95% confidence interval [CI]: 0.27, 0.49) for all ELBW infants, 0.20 (95% CI: 0.10, 0.35) for the neurosensory-intact subgroup, and 0.61 (95% CI: 0.42, 0.77) for the neurosensory-impaired subgroup. The negative predictive values were 0.98, 0.99, and 0.85 for the 3 groups, respectively. Neurosensory impairment at 20 months' CA predicted lack of improvement of cognitive function (odds ratio: 6.9; 95% CI: 2.4, 20.2). Children whose cognitive scores improved between 20 months and 8 years had significantly better school performance than those whose scores stayed at <70, but they did less well than those whose scores were persistently >70. CONCLUSIONS: The predictive validity of a subnormal MDI for cognitive function at school age is poor but better for ELBW children who have neurosensory impairments. We are concerned that decisions to provide intensive care for ELBW infants in the delivery room might be biased by reported high rates of cognitive impairments based on the use and presumptive validity of the BSID II MDI.

Chronic conditions, functional limitations, and special health care needs of school-aged children born with extremely low-birth-weight in the 1990s.

CONTEXT: Information on the school-age functioning and special health care needs of extremely low-birth-weight (ELBW, <1000 g) children is necessary to plan for medical and educational services. OBJECTIVE: To examine neurosensory, developmental, and medical conditions together with the associated functional limitations and special health care needs of ELBW children compared with normal-birth-weight (NBW) term-born children (controls). DESIGN, SETTING, AND PARTICIPANTS: A follow-up study at age 8 years of a cohort of 219 ELBW children born 1992 to 1995 (92% of survivors) and 176 NBW controls of similar sociodemographic status conducted in Cleveland, Ohio. MAIN OUTCOME MEASURES: Parent Questionnaire for Identifying Children with Chronic Conditions of 12 months or more and categorization of specific medical diagnoses and developmental disabilities based on examination of the children. RESULTS: In logistic regression analyses adjusting for sociodemographic status and sex, ELBW children had significantly more chronic conditions than NBW controls, including functional limitations (64% vs 20%, respectively; odds ratio [OR], 8.1; 95% confidence interval [CI], 5.0-13.1; P<.001), compensatory dependency needs (48% vs 23%, respectively; OR, 3.0; 95% CI, 1.9-4.7; P<.001), and services above those routinely required by children (65% vs 27%, respectively; OR, 5.4; 95% CI, 3.4-8.5; P<.001). These differences remained significant when the 36 ELBW children with neurosensory impairments were excluded. Specific diagnoses and disabilities for ELBW vs NBW children included cerebral palsy (14% vs 0%, respectively; P<.001), asthma (21% vs 9%; OR, 3.0; 95% CI, 1.6-5.6; P = .001), vision of less than 20/200 (10% vs 3%; OR, 3.1; 95% CI, 1.2-7.8; P = .02), low IQ of less than 85 (38% vs 14%; OR, 4.5; 95% CI, 2.7-7.7; P<.001), limited academic skills (37% vs 15%; OR, 4.2; 95% CI, 2.5-7.3; P<.001), poor motor skills (47% vs 10%; OR, 7.8; 95% CI, 4.5-13.6; P<.001), and poor adaptive functioning (69% vs 34%; OR, 6.5; 95% CI, 4.0-10.6; P<.001). CONCLUSION: The ELBW survivors in school at age 8 years who were born in the 1990s have considerable long-term health and educational needs.

Predictors of internalizing symptoms among very low birth weight young women.

As part of a longitudinal study of the outcomes of very low birth weight children (<1.5 kg), we sought to examine the perinatal, childhood, and young adult predictors of internalizing symptoms among very low birth weight young women and their normal birth weight controls. The cohort included 125 very low birth weight and 124 normal birth weight 20-year-old subjects. Perinatal, childhood, and young adult predictors were examined via stepwise multivariate analyses. Results revealed very low birth weight to be a significant predictor of parent-reported internalizing symptoms of their daughters but only among white subjects who had mothers with high levels of psychological distress. Additional significant predictors of 20-year internalizing symptoms included child I.Q. and internalizing symptoms at age 8 years and family expressiveness. When the results were analyzed according to the young adult self-report, additional predictors of internalizing symptoms included a history of asthma and exposure to violence. Perinatal risk factors were not found to be predictive of internalizing symptoms at age 20 years. Future studies should prospectively examine social and environmental factors associated with the neonatal intensive care experience that might explain the effect of very low birth weight on later psychopathology.

Behavioral outcomes and evidence of psychopathology among very low birth weight infants at age 20 years.

OBJECTIVE: Information on the mental health of very low birth weight (VLBW; <1500 g) children in young adulthood is sparse. We thus sought to examine gender-specific behavioral outcomes and evidence of psychopathology in a cohort of VLBW young adults at 20 years of age. METHODS: We compared a cohort of 241 survivors among VLBW infants who were born between 1977 and 1979 (mean birth weight: 1180 g; mean gestational age at birth: 29.7 weeks), 116 of whom were men and 125 of whom were women, with 233 control subjects from the same population in Cleveland who had normal birth weights (108 men and 124 women). Young adult behavior was assessed at 20 years of age with the Achenbach Young Adult Self-Report and the Young Adult Behavior Checklist for parents. In addition, the young adults and parents completed the ADHD Rating Scale for Adults. Gender-specific outcomes were adjusted for sociodemographic status. RESULTS: VLBW men reported having significantly fewer delinquent behaviors than normal birth weight (NBW) control subjects, but there were no differences on the Internalizing, Externalizing, or Total Problem Behavior scales. Parents of VLBW men reported significantly more thought problems for their sons than did parents of control subjects. VLBW women reported significantly more withdrawn behaviors and fewer delinquent behavior problems than control subjects. Their rates of internalizing behaviors (which includes anxious/depressed and withdrawn behaviors) above the borderline clinical cutoff were 30% versus 16% (odds ratio: 2.2; 95% confidence interval [CI]: 1.2-4.1). Parents of VLBW women reported significantly higher scores for their daughters on the anxious/depressed, withdrawn, and attention problem subscales compared with control parents. The odds ratios for parent-reported rates above the borderline-clinical cutoff among women for the anxious/depressed subscale was 4.4 (95% CI: 1.4-13.5), for thought problems was 3.7 (95% CI: 1.2-11.6), and for attention problems was 2.4 (95% CI: 1.0-5.5). There were no differences in the young adult self-report of attention-deficit/hyperactivity disorder (ADHD). Parents of VLBW men reported higher mean scores on the attention subtype of ADHD but not higher rates of ADHD. CONCLUSION: The increase in psychopathology among VLBW survivors in young adulthood indicates a need for anticipatory guidance and early intervention that might help to prevent or ameliorate potential psychopathology.

Development and validation of school-based asthma and allergy screening questionnaires in a 4-city study.

BACKGROUND: Asthma and allergies are commonly undiagnosed in children. Schools provide settings for potentially accessing almost all children for asthma and allergy screening. OBJECTIVE: To evaluate the feasibility and validity of using a questionnaire-based screening tool to identify undiagnosed asthma and respiratory allergies in children in kindergarten to grade 6. METHODS: A student questionnaire (SQ) and a parent questionnaire (PQ) were developed, administered in 4 diverse communities, and validated against standardized clinical assessments. Children without diagnosed asthma and representing a range of symptoms participated in a validation study that consisted of independent, standardized, clinical assessments. Sensitivity, specificity, and predictive values for questionnaire items were evaluated against expert consensus designations. RESULTS: A total of 190 children (age range, 7-13 years) completed the validation study. Affirmative responses to individual questions from either the SQ or PQ regarding asthma and allergy were modestly to moderately predictive of the clinical assessments (odds ratios, generally 2.5-5.0). When considering a positive asthma screen as affirmative responses to 3 of the best 7 SQ asthma questions, the odds ratio for asthma was 9.3 (95% confidence interval, 4.1-21.1), with 80% sensitivity and 70% specificity. Considering the allergy screen as positive based on affirmative response to either of the 2 SQ allergy questions yielded 81% sensitivity and 42% specificity. CONCLUSIONS: Either a 9-item SQ or a 10-item PQ can be used in diverse settings to screen for asthma and respiratory allergies. The SQ, obtained by directly screening students, may provide a sensitive approach for detecting children with previously undiagnosed asthma and allergies.

Growth of very low birth weight infants to age 20 years.

OBJECTIVE: Intrauterine and neonatal growth failure of very low birth weight (VLBW; <1500 g) infants may influence adult growth attainment and have long-term implications for adult health. As part of a longitudinal study of VLBW infants, we sought to examine gender-specific changes in growth from birth to 20 years old and to identify the correlates of growth attainment at 20 years old. DESIGN, SETTING, PARTICIPANTS: A cohort of 103 male and 92 female VLBW infants who had a mean birth weight of 1189 g and mean gestational age of 29.8 weeks, were born from 1977 through 1979 and treated at Rainbow Babies and Children's Hospital in Cleveland, Ohio, and were free of neurosensory impairment were followed prospectively from birth and compared with a population-based sample of 101 male and 107 female normal birth weight (NBW) controls selected at 8 years old. Maternal sociodemographic status and infant birth and neonatal data did not differ significantly between male and female VLBW subjects. However, male VLBW subjects had significantly higher rates of rehospitalization during infancy than female VLBW (39% vs 21%). At 20 years, their rates of chronic illness were similar (18% vs 24%). MAIN OUTCOME MEASURES: Weight and height z scores were computed at birth, 40 weeks, 8 and 20 months, and 8 and 20 years among the VLBW subjects, and at 8 and 20 years among the NBW controls. Body mass index (BMI) z scores were computed at 8 and 20 years. Among the VLBW subjects, gender-specific longitudinal growth measures were examined at birth, at the expected term date (40 weeks corrected age), and at 8 and 20 months, and 8 and 20 years of age. In addition, we compared the weight, height, and BMI of the VLBW and NBW controls at 8 and 20 years. Predictors of 20-year growth were examined via multivariate analyses. RESULTS: Among the VLBW males, mean weight for age z scores at birth, 40 weeks, and 8 years were -0.7, -1.8, and -0.5; and height for age z scores were -1.2, -2.6, and -0.5, respectively. For VLBW females, mean weight for age z scores were -1.1, -2.0, and -0.2 and height for age z scores were -1.2, -2.4, and -0.2, respectively. At 8 years of age, VLBW males had a significantly lower mean weight, height, and BMI than NBW controls, whereas VLBW females differed significantly from their NBW controls in mean weight and BMI but not in height. Catch-up growth in weight, height, and BMI occurred between 8 and 20 years among VLBW females but not among VLBW males who remained significantly smaller than their controls at 20 years old. At 20 years mean weight of VLBW males was 69 kg versus 80 kg for controls (z score -0.4 vs +0.5); mean height was 174 cm versus 177 cm (z score -0.4 vs +0.03) and mean BMI was 23 versus 26, respectively. For VLBW females, mean weight was 65 kg versus 68 kg for controls (z score +0.3 vs +0.5), mean height was 162 versus 163 cm (z score -0.3 vs -0.1) and mean BMI was 25 versus 25, respectively. Rates of obesity (BMI >30) for VLBW males were 7% compared with 15% for controls and for VLBW females 15% compared with 18% for controls. Age of menarche was 12.4 years for VLBW females and 12.3 years for controls. Nineteen (18%) male and 20 (22%) female VLBW subjects were born small for gestational age (SGA; weight less than -2 standard deviation for gestational age). At 20 years, significantly more SGA than appropriate for gestational age VLBW males remained subnormal (less than -2 standard deviation) in weight (32% vs 6%) and height (21% vs 4%), whereas rates of subnormal growth did not differ significantly between SGA and appropriate for gestational age females (weight 5% vs 1%, height 0% vs 7%). Predictor variables included in the multivariate analyses of 20-year growth attainment were maternal education and height, race, birth weight z score (a measure of intrauterine growth failure), neonatal hospital stay (a measure of neonatal illness), and chronic illness at 20 years. Twenty-year weight was predicted by black race and chronic illness among females. Twenty-year height was predicted by maternal height and birth weight z score among both males and females and by duration of neonatal hospital stay among males only. In a separate model, when we examined the effect of being SGA at birth instead of the effect of birth weight z score, SGA birth was predictive of 20-year height among males but not among females. CONCLUSIONS: VLBW females catch up in growth by 20 years of age whereas VLBW males remain significantly shorter and lighter than controls. Since catch-up growth may be associated with metabolic and cardiovascular risk later in life, these findings may have implications for the future adult health of VLBW survivors.

Outcomes in young adulthood for very-low-birth-weight infants.

BACKGROUND: Very-low-birth-weight infants (those weighing less than 1500 g) born during the initial years of neonatal intensive care have now reached young adulthood. METHODS: We compared a cohort of 242 survivors among very-low-birth-weight infants born between 1977 and 1979 (mean birth weight, 1179 g; mean gestational age at birth, 29.7 weeks) with 233 controls from the same population in Cleveland who had normal birth weights. We assessed the level of education, cognitive and academic achievement, and rates of chronic illness and risk-taking behavior at 20 years of age. Outcomes were adjusted for sex and sociodemographic status. RESULTS: Fewer very-low-birth-weight young adults than normal-birth-weight young adults had graduated from high school (74 percent vs. 83 percent, P=0.04). Very-low-birth-weight men, but not women, were significantly less likely than normal-birth-weight controls to be enrolled in postsecondary study (30 percent vs. 53 percent, P=0.002). Very-low-birth-weight participants had a lower mean IQ (87 vs. 92) and lower academic achievement scores (P<0.001 for both comparisons). They had higher rates of neurosensory impairments (10 percent vs. <1 percent, P<0.001) and subnormal height (10 percent vs. 5 percent, P=0.04). The very-low-birth-weight group reported less alcohol and drug use and had lower rates of pregnancy than normal-birth-weight controls; these differences persisted when comparisons were restricted to the participants without neurosensory impairment. CONCLUSIONS: Educational disadvantage associated with very low birth weight persists into early adulthood.