long-term outcomes of prematurity gehan roberts centre for community child health, rch murdoch...
TRANSCRIPT
Long-term outcomes of Prematurity
Gehan Roberts
Centre for Community Child Health, RCHMurdoch Childrens Research Institute
Department of Paediatrics, University of Melbourne
Contents
• Introduction– Definition– Prevalence
• History• Outcome studies– Changes over time
• Intervention studies• Future directions
Definition
Term: >=37• Preterm <37/40– Late preterm: 33 to 36+6– Very preterm: 28 to 32+6– Extremely preterm: <28• Alternative classifications based on birthweight– LBW <2500g– VLBW <1500g– ELBW <1000g
Prevalence
• Late preterm ~7% • Very preterm ~1-2%
• Victoria: 60-75,000 births p. year– About 5000 preterm– About 750 very preterm
History
• Victorian Infant Collaborative Study– ELBW infants (500-999g)– + <28/40 after 1991
• 5 cohorts– 1979-80, 1985-87, 1991-92, 1997, 2005
ELBW infants in Victoria
1979-80 n=351 (3.03/1000 livebirths) 175/yr
1985-87 n=560 (3.06/1000 livebirths) 187/yr
1991-92 n=429 (3.29/1000 livebirths) 215/yr1997 n=233 (3.77/1000 livebirths)
233/yr2005 n=257 (3.88/1000 livebirths)
257/yr
Traditional Outcomes
• Survival– Discharge– 2 years
• Neurological disability– Deafness– Blindness– Cerebral Palsy
Developmental outcomes
• Increasingly important– More very tiny babies surviving to school-age and
adulthood
• Need to compare outcomes against a control group– How are they doing compared with same-age
peers?
Cognitive Delay: age 2
0%
20%
40%
60%
80%
100%
79-80 85-87 91-92 1997 2005
nil mild moderate severe
% survivors
Era
What about older children?
• Cognitive skills– IQ– Language– Attention, Executive function
• Educational outcomes• Behavioural and Psychological outcomes– Autism, ADHD, mood problems
School readiness • ‘School readiness’
– Term 1st used a century ago– Assessment framework for understanding profiles
of strengths and vulnerabilities of the preschool-age child
• Very preterm children are at high risk of difficulties in school– 50% have academic/ behavioural difficulties
• Understanding readiness to learn– potential to aid successful transition into school
Definition• Three key attributes
– Children who are ready to learn– Schools that are ready for children– Parents and communities who support the child’s
development. • Readiness to learn is further divided into 5 skill areas
– 1) Health and physical development– 2) Emotional well-being and social competence– 3) Approaches to learning– 4) Communication skills– 5) Cognitive skills and general knowledge.
– Copple, National Educational Goals Panel, 1997
Cumulative number of areas of difficulty
0
10
20
30
40
50
60
70
80
1 2 3 4 5 6
Number of Domains
Pro
po
rtio
n
VPT
Control
0 1 2 3 4 5
Relationship between gestation and IQ
‘Preterm and low birth weight babies’, Dieter Wolke,Sage Handbook of Developmental Disorders
Relationship between gestation and IQ
‘Preterm and low birth weight babies’, Dieter Wolke,Sage Handbook of Developmental Disorders
‘Preterm behavioural phenotype’: increased inattention, anxiety, social difficulties
-Johnson et al, Ped Res, 2011
Prevalence of psychiatric disorders at 11 y of age in a population-based cohort 219 EPT (26 wk) children (BLUE)152 term-born classmates (RED) -UK EPICure Study
Swedish national cohort of 1 180 616children born between 1987 and 2000, followed up for ADHD medicationin 2006 at the age of 6 to 19 years
•Compared with term controls, VLBW adults (age 21 y) are…•More conscientious•Agreeable•Less open to new experiences•Less hostile or impulsive•Less assertive
•Independent of age, gender, school achievement, parental education, maternal health
•Pesonen et. al, Helsinki Study of VLBW adults, J Ch Psychol. Pstychiatr. 2008
•Compared with term controls, VLBW adults (age 21 y) are…•More conscientious•Agreeable•Less open to new experiences•Less hostile or impulsive•Less assertive
•Independent of age, gender, school achievement, parental education, maternal health
•Pesonen et. al, Helsinki Study of VLBW adults, J Ch Psychol. Pstychiatr. 2008
Preterm personality profilePreterm personality profile
Meta-analysis of logistic regressions of leisure timephysical activity as a function of birth weight. The points depictlog(OR) and corresponding 95% confidence intervals
Birth Weight in Relation to Leisure Time Physical Activityin Adolescence and Adulthood: Meta-Analysis of Resultsfrom 13 Nordic Cohorts. Andersen et al. PLoS ONE, 2009
Respiratory health
Preterm children, compared with term controls, have…•More hospital readmissions with URI/ LRIs•More airway obstruction•Poorer exercise tolerance
……in childhood, adolescence and early adulthood.
•This has not been affected by the introduction of Surfactant•Smoking probably contributes to worsening of these outcomes•Those who had BPD as neonates do worse than those who did not.
Quality of life
•Young adults born preterm:•report no differences in the self-reported quality of life despite recognition of their disabilities•‘the disability paradox’
•ELBW and control adolescents and their parents provide higher ratings of health-related quality of life for severely disabling hypothetical health states than did health professionals.
•Saigal, Lancet, 2008
Future directions
• Intervention– Long-term follow-up of promising NICU
interventions• Caffeine, DHA, antenatal Magnesium
– Interventions targeted to areas of vulnerability• Working memory• Social-emotional development
– Novel intervention delivery• Web-based?