ASSESSMENT OF THE PRETERM NEONATE: STATE OF THE ART.
This is a report of a meeting of the Forum on Maternity and the Newborn of the Royal Society of Medicine, held on Monday 18th September 2006.

Morning session, chaired by Dr. Anita Holdcroft, Reader in Anaesthesia and Consultant Anaesthetist, Chelsea and Westminster Hospital and Imperial College London.
EARLY ASSESSMENTS - SCOPE AND APPLICATION.

The neuropsychological screening of the preterm infant before discharge from hospital.

Dr Romana Negri (RN), Professor of Child Neuropsychiatry, Milan University and Sacco Hospital, Italy

In the field of neonatal neurology the importance of the early detection of emotional suffering has rightly been stressed. For this reason several descriptive elements are taken into consideration during the neonatal period and early infancy, because in some cases they can define true syndromes: the hyperexciteability, apathetic and transient dystonic syndromes, irritability, hypo-reactivity, tremor, different types of crying, and sleep disorders. Nevertheless, for diagnostic purposes these findings cannot be interpreted neurologically: in a Touwen (1989) study of newborns manifesting these signs, only 10% developed cerebral palsy. It is evident that identical signs may show different prognoses; therefore the presence of any of these syndromes is not necessarily an indication of a neurological disorder.

In these early months motor behaviour reveals significant evolutionary residues; the appropriate neural and functional adaptation to the extrauterine environment has yet to mature, and this usually takes place only after two to three months. Compared to other primates the human infant lacks significant coping abilities, and this points to the importance of the role of the mother in his development. Physical contact with the mother cannot be considered as merely the most suitable method facilitating the development of motor functions; it also has an important role in the context of the perception and understanding of emotional communication, the basis of the development of thought and symbolisation and of the baby's self-integration.

Only after the fourth month does a baby maintain a symmetrical posture when lying on his back; now he is capable of taking hold of objects with two hands, looking at them and taking them to his mouth. The upper limbs take on the function of the psychomotor antennae so necessary for the baby's development and acquisition of knowledge. Now he individualises and can live completely as an entity, demonstrating the integration of mental processes within neurological development; this has enabled me to understand how impossible it is to separate the physical and mental components of the newborn.

The early detection of brain damage in the newborn infant is of the greatest importance, since when treatment is given promptly it can enable the functional damage caused by the lesion to be reduced even though repair of the central nervous system is not possible; subsequent development is optimised. However a strictly neurological interpretation of results is not exhaustive in terms of diagnosis, and correlations between "transitory anomalies" (Amiel-Tison and Dube 1985), "soft signs" (Touwen 1989) and learning difficulties at school age have been identified.

That emotional factors are active not only from birth but also in the intrauterine environment is supported by psychoanalysis, neurophysiological study and ultrasound research. I express the difficulty of differentiating between somatic and mental functions at such an early age thus: "The newborn feels with his body and uses it to express himself". Indeed he expresses deep and extremely intense emotions by the use of activity, and it is important to recognise his tendency to experiment with bodily sensations in differentiating emotions such as joy, suffering, and wellbeing.

Newborns may show a lack of postural variability, common to both psychopathology and cerebral palsy, which induce anxiety and physical defence mechanisms. These conditions respond in the same way to the traumatising environment of the neonatal intensive care unit (NICU). The infant at risk is capable of demonstrating pathological characteristics through its mental activities at this very early stage of development, and I have drawn up a table of alarm symptoms which indicate psychopathological risk (Appendix).

Although the alarm symptoms can be present in a healthy infant to a limited degree, they are abundantly present in the infant at risk and are apparent in repetitively expressed aspects of his personality. Being so dominantly expressed alarm symptoms hinder the infant's sensory integration and interfere with his relationship with his mother, who is equipped to satisfy a newborn's needs.

Assessment.
We make our neuropsychological assessment when a preterm infant approaches his term date and is about to be discharged from hospital, and in the presence of the parents and nurses who have cared for him throughout. Assessment of his level of neurological maturation and any eventual central nervous system damage is observed while he is still in the incubator. Observation of the quality and variability of movement and of the achievement of spontaneous movement are key features of the assessment; this has been significantly influenced by ultrasound research into fetal motility. The concept of variability is very useful as a means of distinguishing between normal and deviant functioning in the early stage of brain disorder" (Touwen, 1989).
The assessment itself has therapeutic value, highlighting to the parents the most positive features and characteristics of their baby; I underline the importance of holding the baby in one's arms, looking him in the eyes and speaking to him, so allowing him to express the distress he has experienced during hospitalisation in terms of illness, loneliness, and traumatic medical procedures. The possible alarm symptoms are explained and the importance of follow up emphasised; when serious neurological damage is likely a rehabilitation programme is set up early, and the physiotherapist is introduced to the parents then.

Examination.
The baby's responses to internal and environmental stimuli greatly depend on his level of consciousness, and any interpretation of them needs to take this into consideration; it is important to note any changes in the state and other features of these responses, since the way in which the infant organises or controls various states at around the forty-second week is vital for the prognosis of mental development. The baby's condition can be considered well under control as soon as he remains in a well-defined state for significant periods of time and with a smooth, gradual transition from one state to another. Sudden changes are indicative of the child's vulnerability, made apparent by his motor and postural behaviour; vulnerability affects emotional stability.
The assessment format is very similar to those proposed by French researchers (Thomas & Autgaerden 1966; Saint-Anne Dargassies 1972, 1974) and to those to which the Bobaths (1980) refer in their proposed rehabilitation programme for cases of child cerebral palsy. It is particularly important to detect the appearance of the rhythmical vocal communication which characterises the baby-mother relationship and which started in the uterus; it has great prognostic significance, and is inhibited where there is a risk of psychopathology or if the mother is depressed or otherwise distressed. I do not subject the baby to the stimuli of light or sound, preferring to observe the spontaneous attention the baby pays to objects and people. He will however be subjected to tests of vision and hearing in early infancy.
I believe it is beneficial for the baby to be comforted in his mother's arms. This can demonstrate his ability to recognise his mother, a recognition attributable in particular to the senses of smell and hearing which are already active by the fourth month of prenatal life. Consolability and cuddliness as defined by Brazelton (1973, 1984, 1995), and in general the infant's readiness to accept and enjoy the dependency and protection offered by the adult are valuable observations. In this way it is possible to see in the baby not only an expression of biological satisfaction but also the start of mental activity. By holding the glance of the examiner, trying to grasp onto her clothing , laying his open hand onto her chest and maintaining eye contact with her the baby expresses a desire to see and make contact with the source of his sense of wellbeing.

It may actually happen that extremely preterm infants or those suffering from cerebral pathology demonstrate excessive interest in objects or sensory stimuli, and this attraction may interfere with the process of attachment (Robson 1970) and lead to the infant increasingly excluding himself from relationships. It has also been noted that a mother who has been traumatised by the experience of premature birth or her baby's pathology, and who lives in a state of anguish, is not seen by her baby as distressed, but rather as a person concerned about herself, uncomprehending, rejecting others and hostile to the relationship with her child. Such emotions are picked up by a baby who is highly vulnerable, thus leading to a sense of isolation. There is a risk of his developing primitive defensive mechanisms that are used to protect himself from emotions connected with relationships, particularly that with the mother. This may lead to his favouring repetitive experiences with sound and movements (for example protrusion of the tongue from the mouth) which offer the baby some sort of gratification on the sensory level, relieve strain and hinder the baby from establishing an adequate relationship with its environment. The same significance is acquired by the obstinacy often displayed by infants when they seek sensory perceptions derived from the objects to which they are attracted because of their colour, brightness or sound. Problems may also be caused if an anxious mother overstimulates her baby in the hope of speeding his development.

Appendix.

ALARM SYMPTOMS

· Averting the gaze.
· Slipping away of eye contact.
· Pretending to sleep.
· Spying when unobserved.
· Looking around restlessly.
· Absence of smiling.
· Absence of crying.
· Stiffness of facial expression.
· Absence of mother-child vocal rhythmicity.
· Rejection of having the back and neck supported.
· Not enjoying being cuddled.
· Tremor (especially during the first two months).
· Hiccupping (especially during the first two months.)
· Stereotypes (such as repetitive sounds, hand gestures etc.).
· Abnormal reaction or response to sounds or voices.
· Excessive or strange interest in movements of the tongue.
· Motor restlessness.
· Postural anomalies.
· Cutaneous, intestinal (colic) or respiratory psychosomatic manifestations.
· Fear of having the feet or hands stroked.
· "Little-hat" phobia (fear of having the head stroked).
· Fear of being undressed.
· Other fears.
· Feeding disorders, anorexia.
· Major alterations in biological rhythms (most frequently sleep disorders, irritability).

References.

Amiel-Tison C., Dube R. (1985) Significance of transitory neuromotor abnormalities. Correlation with difficulties in school-age years. Ann Pediatr (Paris) 32(1):55-61

Touwen BCL. (1989) Early detection and treatment of cerebral palsy: possibilities and fallacies. Giornale di Neuropsychiatria dell'Età Evolutiva 4: 31-38

Saint-Anne Dargassies S. (1972) Neurodevelopmental symptoms during the first year of life: Part I. Essential landmarks for each key-age. DMCN 14: 235-246.

Saint-Anne Dargassies S. (1972) Neurodevelopmental symptoms during the first year of life: Part II. Practical examples of the assessment method to the abnormal infant. DMCN 14: 247-264

Bobath, B. & Bobath. K. (1980) Student's Papers. London: The Bobath Centre.

Bobath. B. (1980) The Very Early Treatment of Cerebral Palsy. Developmental Medicine and Child Neurology 9(4): 373-390.

Brazelton. T. B. (1973) Neonatal Behavioral Assessment Scale. Spastics International Medical Publications. London: Heinemann Medical.

Brazelton. T. B. (1984) Neonatal Behavioral Assessment Scale. Lavenham, Suffolk: Lavenham Press.

Lester. B. M., Boukydis, C. F. Z., McGrath, M., Censullo, M., Zahr, L.. & Brazelton. T. B. (1990) Behavioral and Psychophysiologic Assessment of the Preterm Infant. Clinics in Perinatology 17(1): 155-171.

Paine, R. S., Brazelton, T. B., Donovan, D. E., Drorbaugh, J. E., Hubbell. J. P.. & Sears, E. M. (1964) Evolution of Postural Reflexes in Normal Infants and in the Presence of Chronic Brain Syndromes. Neurology 14: 1036-1048.

Prechtl. H. F. R, & Beintema, B. J. (1964) A Neurological Study of Newborn Infants. Clinics in Developmental Medicine, No. 28., London: Heinemann.

Robson, K. S.,Moss, H.A. (1970) Patterns and Determinants of Maternal Attachment. Journal of Pediatrics 77(6): 976.

Robson, K. S. (1967) The Role of Eye-to-Eye Contact in Maternal Infant Attachment. Journal of Child Psychology 8: 13-25.

Discussion

RN: Little hat phobia - a premature baby's fear of having his head stroked or of other touching is associated with the recollected pain of some clinical procedures, particularly the introduction of infusions via the scalp veins. Happily neonatologists have been working to minimise such pain.

The chair asked whether the assessment is varied in the case of babies born of multiple pregnancies, where it might be supposed that they are exposed to the behaviours of their siblings in utero. Responding, the Forum President Dr. Elvidina Adamson-Macedo told us that this is not at present taken into consideration.

RN: I do not use a measurement scale to quantify the infant-maternal responses and psychological states, but rely on my observations, which I note during follow up. I realise that this is a skill which cannot be taught; the student will also have to rely on experience.

There is as yet no remedy with which to intervene on behalf of these babies with brain damage or cerebral palsy. Research leading to therapy is overdue. RN: All we can do at present is to help the mother to form a close relationship with her baby. Much as I value technical means of observation such as Prechtl and MRI, I could wish that they are always associated with psychological assessments.
JC: Mothers can be overwhelmed by the needs of physical care for their babies, but they should as early as possible and before leaving the hospital be helped to understand the value and importance of holding, touching, and eye contact.
FC: I hope that neonatal units are learning the importance of having quiet periods when babies are not being subjected to clinical interventions, and realise the importance of talking to babies before picking them up. Premature and brain-damaged babies have more gastro-oesophageal reflux than others, and there is value in assiduous treatment of this to make them more comfortable. It is also important and valuable to optimise the environment by supporting the families of these babies.

It has been said that the infant's brain develops in the context of a relationship with another self and another brain. In other words different environments result in the development of different brains; much depends on the habit pattern of the mother, but in the setting of the neonatal unit very early interventions may be vital. For example a 34-week baby with cerebral palsy may, when oral feeding starts, develop a harmful extended position of the head; this can and should be corrected, so that brain growth can proceed upon healthier lines in this respect. Skin to skin contact and kangaroo care have their part to play also.

There is a realistic anxiety that telling a mother that her baby has brain damage can so adversely influence the mother-infant relationship as to inhibit optimum development thereafter. It may be best to promote as good a relationship as possible between mother and baby while keeping the mother in ignorance, until informing her becomes unavoidable. RN: Progress should be monitored and the mother's confidence encouraged by frequent meetings with the doctor and neonatal staff, but keeping her in ignorance is not an option.

RN: If a mother is too unwell physically or psychologically to care for her baby other members of her family, from siblings to grandparents, can successfully be recruited for this important role. The carer should provide physical contact as well as speech by supporting the baby behind his neck.
A nurse practitioner: Sometimes a nurse will need to be a substitute in the role, and some parents, particularly young ones or former drug abusers, may need basic instruction before they can begin to form relationships with their babies.

Asked whether a physical effect on brain development can be demonstrated following interventions - FC: It is very difficult to randomise trials using MRI scans for the purpose, although there are small and accordingly unsatisfactory studies which suggest a benefit, in one instance from the use of regular if rather brief skin to skin contact. Such research is inhibited in departments which hold a strong belief in their own interventions and are unwilling to consider randomisation.
JC: This opens up a huge field of study when you consider that so little is known about which interventions are appropriate at any stage of development, aware as we are that this may change from week to week.

Asked whether there is evidence over time validating preterm assessments, a speaker cited the Neurobehavioral Assessment of the Preterm Infant(NAPI) as having passed this test. Both the NAPI and the Brazelton assessments can predict outcome in terms of psychology by the interpretation of behaviours such as crying, consolability and self-integration.

Afternoon session, chaired by Dr. Maggie Redshaw, Social Scientist, National Perinatal Epidemiology Unit, Oxford.
EARLY ASSESSMENT AND LATER DEVELOPMENTAL OUTCOME.


Neurobehavioural assessment predicts differential outcomes between VLBW and ELBW preterm infants.
Dr. Janet Constantinou, Development Specialist, Lucile Packard Children's Hospital at Stanford University, Palo Alto, USA
(Co-author)

My objective here is to evaluate the impact of birth weight on the development of very low birth weight infants using the Neurobehavioral Assessment of the Preterm Infant (NAPI) before hospital discharge, and to show how it predicts follow up outcomes at 12, 18 and 30 months of age.

About 4 million babies were born in the USA in 2003, half a million of them prematurely. Of those 6.0% were of very low birth weight (VLBW), between 1500 and 1000 grams, and 4.6% of extremely low birth weight (ELBW), less than 1000 grams. As the number of these babies who survive increases we are faced with more of the problems which are their lot. The frustration of parents who cannot interact fully with babies who are frequently very irritable, and who may bring an increased workload by being multiple, leads to a higher incidence of abuse. There may be gastro-oesophageal reflux and feeding difficulties, vision and hearing handicaps and a need for oxygen therapy at home. Early intervention services are required, and this adds to the pressure on families; at this time such interventions have not reduced the proportion of children reaching school age who need special education to below 45%. We studied 53 VLBW and 60 ELBW babies at equivalent postconceptional ages (PCA), hoping to be able to determine whether there were differences in development between the two groups, whether such differences are maintained over time, and whether our method of assessment, the NAPI, was sufficiently discriminating to detect differences. The racial distribution was white 44%, Latin 28%, 13% Asian and 11% black; 43% were multiples, and 56% were male.

We used the NAPI at 36 weeks PCA, when most babies are off ventilation and infusions, and before they leave hospital. At 12 months PCA we used the Bayley infant neurodevelopmental 11 item screener (BINS), and the full Bayley Scales of Infant Development at 18 and 30 months. The NAPI is a measure of relative maturity that has been tested with over 1000 babies, and was carefully designed to elicit the optimum behavioural state of the infant for each manoeuver. Its psychometric properties, developmental validity, test-retest and inter-rater reliability and normative data from 32-37 weeks corrected age are among its strengths, as is its freedom from stress on the babies. Now lasting 30 minutes, it has an invariant sequence of items, and it serves as a basis for follow up.

We categorise our assessment into domains which we have strengthened by adding items with conceptual and coherent validity. Results can be compared with normative data provided in the NAPI manual. We have seven domains, three of which have single items because they did not cohere logically with any other items. We have avoided repeating items as these babies tire so easily.

· Motor development is chiefly assessed by testing reflexes and vigour.

· Alertness and orientation tell us a lot about state regulation, noting the responses to stimulation by voice and rattle, the degree of tracking, and the ability to sustain attention. This domain is predictive of Mental Development Index (MDI) Bayley scores.

· Irritability has no predictive power in this study. It may reflect a baby's temporary condition, but it can indicate a pending difficulty for the mother.

· The scarf sign, popliteal angle and cry quality are useful in conjunction with the other domains, but are not themselves predictive.

· The percentage of time asleep reduces as a baby matures with a well understood pattern.

An assessment will not be completed unless undertaken at a time which is right for the baby, hence the choice of 36 weeks PCA and 45 minutes before a feeding., Any immediately preceding intervention such as examination of the eyes or MRI is likely to tire the baby and vitiate a successful assessment. So we don't do it immediately before a feed, when the baby is hungry, or immediately after, when it may precipitate posseting. Serial examinations would enable us to track progress or the lack of it, but prove impractical because of the lack of staff time. The presence of the parents at the examination is rewarding and instructive for them. The resuslts show that ELBW group was significantly less mature than the VLBW group on the NAPI alertness domain, and had lower scores on the BINS and Bayley MDI. No significant differences were found between groups on the NAPI motor development domain, and this continued to be true on the Bayley Psychomotor Development Index (PDI).

Differences in weight and head circumference between ELBW and VLBW babies continue to be significant from 4 months through 30 months. 14% of all subjects developed cerebral palsy (CP). CP is much more prevalent in the ELBW group, and it is in this group that development and state regulation are significantly delayed. However, when the CP infants were excluded from the analysis, the ELBW group still remained significantly delayed throughout the period of studyWhen they leave our care we refer those babies which are in need of services, to local agencies but demand often outstrips supply. We have identified barriers to necessary early intervention, but community agencies may differ in their assessment of eligibility for services, leading to excessive delay in their implementation; there may be poor coordination of services, language and transportation barriers. Among immigrants there is fear that a family's immigration status may be affected, information overload may lead to confusion over which programmes are available, and socio-economic status and public policy have major impacts on the situation.

Bibliography.

Korner, A.F., Brown, J.V, Thom, V.A., Constantinou, JC (2000) Neurobehavioral Assessment of the Preterm Infant. Child Development Media, Van Nuys, California.

Constantinou, J.C., Korner, A.F. (1993). Neurobehavioral Assessment of the preterm Infant as an instrument to enhance parental awareness. Children's Health Care 22 (1): 399-46

Korner, A.F., Kraemer, H.C. et al. (1987). A methodological approach to developing an assessment procedure for testing the neurobehavioral maturity of preterm infants. Child Development 58: 1478-87.

Constantinou J.C., Adamson-Macedo, E. N., Mirmiran M., Fleisher B.E. (2005) Neurobehavioral Assessment Predicts Differential Outcome Between VLBW and ELBW Preterm Infants. J Perinatology. 00: 1-6.

Early clinical assessment in preterm infants: relation to brain imaging and 6-year development outcome.
Dr Frances M. Cowan (FC) , Senior Lecturer in Perinatal Neurology, Department of Paediatrics, Imperial College, Hammersmith Hospital, London (Co-author)

Paediatricians seem to be inhibited in their physical examinations of premature babies by a perception that it is too difficult and not productive; however with some time and experience it is generally not difficult to define tone patterns, and document facial activity, a baby's ability to fix on and follow a target and his auditory responses, the patterns of his movements and changes in behaviour over time. Our simple tools include a small hammer and torch, a plastic washable rattle (not a bell), and washable plasticised visual targets; we measure the head circumference, and make videos of the babies. We can detect many brain abnormalities as well as brain and in recent years from MRI scans growth or the lack of it from cranial ultrasound scans. Lilly Dubowitz (Dubowitz et al. 1995) designed a clinical neonatal neurological examination which is easy to perform for infants in incubators, requires little equipment, shows good inter-observer correlation, includes a variety of neurological functions - posture, tone, motility, reflexes, and behaviour - and is useful in both clinical and research settings. The forms used for her method of examination provide ease of recording using schematic diagrams.

Figure


Figure: A section of a proforma showing five possible responses to leg traction (upper panel) and five different measurements of the popliteal angle (lower panel). The squares to the right show the most common columns (with percentages) in which responses are found in preterm infants of different birth gestations at term equivalent age (3 upper lines) and the optimal column for newborn term infants (lowest line). NB that for preterms at term age the column is to the left, i.e. tone is less and the popliteal angle greater than in newborn term infants.

We also observe infant movements as a simple alternative to the Prechtl video technique, and emphasise the importance of assessment of alertness by observation of responses to visual stimuli. A neurological optimality score (max score 34, optimal considered as more than 30.4 achieved by 95% of this population) was developed using this examination in over 200 low-risk, well newborn term infants (Dubowitz et al. 1998). It has been applied to infants born preterm with normal cranial ultrasound scans and we have shown distinct differences in tone patterns in this patient group (Mercuri E et al. 2003) from the term born infant (Figure). They tended to have less flexor tone in their limbs compared to the term infants, and only 15-18% of these infants achieve the optimal scores found in the term born infant. The question of what is optimal for a preterm infant at term postconceptional age (PCA) remains unanswered.

Comparison of the Hammersmith neonatal examination with the Brazelton (Brazelton T.B. 1984) showed the latter examination to have slightly better predictive powers, but it takes very much longer, and is far less practical in daily clinical use (Brown N PhD Melbourne 2006).

We have developed an infant examination for children at 12 and 18 months (and later shown it to be applicable from 6 months, Haataja L 2003) and constructed an optimality scoring system from it in a group of 110 of the term born children, all considered normal, whom we had seen when developing the neonatal examination (Haataja L et al. 1999). The neurological items tested are assessment of cranial nerve function, posture, spontaneous movements, tone, and reflexes and reactions, with a maximum possible optimality score (OS) of 78. In term-born infants who had hypoxic ischaemic encephalopathy (HIE) we could show that this exam gave a good prediction of the ability to walk (scores more than 67), sit but not walk (40-67) or not sit (scores more than 40) by 2 years (Haataja L et al. 2001). Persistent low scores also reliably correlated with the pattern of injury seen on neonatal brain MRI scan.

This examination is also helpful in infants born preterm; those with periventricular leucomalacia, examined at 6 - 9 months and with OS above 60 were all able to walk independently at two years. In the OS range 41-60 none was able to walk independently at two years; 9 of 11 were only able to sit and all developed CP. Of 6 children with OS under 40 none were able to sit independently at two years and all had quadriplegia (Frisone et al 2002). Normal reactions - arm protection, vertical suspension, and forward parachute - were strong predictors of normality. Many preterm infants have sub-optimal neurological examinations at 1-2 years but most do not have cerebral palsy (CP) and are independently mobile at 2 years.

Neurological examination at 6 years shows a similar pattern and a high rate of functional difficulty without CP – in our cohort of preterm infants without focal pathology on ultrasound or MRI, 64% have Movement Assessment Battery for Children (MABC) scores below the 15th centile, consistent with our OS at one year to 18 months. A high impairment score on the MABC was associated with thinning of the whole corpus callosum and white matter atrophy. The items that had the poorest scores were coin posting and bead threading. A reduced IQ at 6 years was associated with thinning of the corpus callosum, white matter atrophy and abnormal signal intensity within the centrum semiovale at 1 year and a lower development quotient (DQ) at 2 years. Interestingly, we did not find their smaller head volumes to be directly related to their DQs at age 6 (Dyet L unpublished data).

The interpretation of MRI scans - the location of lesions, abnormal signal in the white matter (Dyet L et al. 2006), the development of the corpus callosum and grey matter, of the cerebellum and of cortical folding (Kapellou O et al. 2006), thalamic size (Boardman J et al. 2006) cortical atrophy, ventriculomegaly, and the absence or presence of myelination - are also important predictive evidence.

MRI can show us diffuse excessive high signal intensity (DEHSI), representing an abnormality widespread throughout the central white matter important for thalamo-cortical connectivity (Counsell S et al. 2007). A global measure of DEHSI has been shown to correlate with later outcome in the absence of major motor deficits (Krishnan M et al 2007 In press) With angiography the simple and straight vascular development in the preterm baby of equivalent age can be compared with the complexity in the term baby; is this caused by nutritional deficiencies and is it the cause of subsequent abnormal outcomes (Malamateniou C et al. 2006).

Many of the children we have studied are doing well, but as found by Marlow et al in their long term follow-up studies of preterm infants many need extra help in school, and attention deficit and minor motor difficulties are common.

References.

Dubowitz L. M., Cowan F., Rutherford M., Mercuri, E. & Pennock J. (1995). Neonatal neurology, past present and future: A window on the brain. Brain and     Development, 17: 22-30

Dubowitz L, Mercuri E, Dubowitz V. (1998) An optimality score for the neurologic examination of the term newborn J Pediatrics 133;406-416

Mercuri E, Guzzetta A, Laroche S, Ricci D, van Haastert I, Simpson A, Beackley C, Luciano R, Frisone MF, Haataja L, Tortorolo G, Guzzetta F, de Vries LS, Cowan F, Dubowitz L. (2003) Neurological examination of preterm infants at term age: comparison with full term infants. J Pediatrics; 142:647-655.

Haataja L, Mercuri E, Regev R, Cowan F, Rutherford M, Dubowitz V, Dubowitz L. (1999) Optimality score for the neurological examination of the infant at 12 and 18 months of age. J Pediatrics;135:153-61

Haataja L, Mercuri E, Guzzetta A, Rutherford M, Counsell S, Frisone MF, Cioni G, Cowan F, Dubowitz L. (2001) Neurological examination in infants with hypoxic-ischaemic encephalopathy at age 9-14 months: Use of optimality scores and correlation with magnetic resonance imaging findings. J Pediatrics;138:332-7

Haataja L, Cowan F Mercuri E, Bassi L, Guzzetta A, Dubowitz L. (2003) Application of a scorable neurologic examination in healthy term infants at age 3 to 8 months. J Pediatrics;143:546

  Frisone MF, Mercuri E, Laroche S, Foglia C, Maalouf EF, Haataja L, Cowan F, Dubowitz L. (2002) Prognostic value of the neurological optimality score in preterm infants born under 31 weeks gestation examined between 9 and 18 months. J Pediatrics; 140:57-60

Dyet L, N. Kennea N, Counsell S, Maalouf E, Ajaye-Obe M, Duggan P, Harrison M, Allsop J, Hajnal J, Herlihy A, Edwards B, Laroche S, Cowan F, Rutherford M, Edwards AD. (2006) Serial magnetic resonance imaging from birth to describe the natural history of brain lesions in extremely preterm infants. Pediatrics. 118(2):536-48

Kapellou O, Counsell SJ, Kennea N, Dyet L, Saeed N, Stark J, Maalouf E, Duggan P, Ajayi-Obe M, Hajnal J, Allsop J, Boardman J, Rutherford M, Cowan F Edwards AD. (2006) Abnormal cortical development after premature birth shown by altered allometric scaling of brain growth. PLoS Med.;3(8):e265

Brazelton. T. B. (1984) Neonatal Behavioral Assessment Scale. Lavenham, Suffolk: Lavenham Press.

Boardman JP, Counsell SJ, Rueckert D, Kapellou O, Bhatia KK, Aljabar P, Hajnal J, Allsop JM, Rutherford MA, Edwards AD. (2006) Abnormal deep grey matter development following preterm birth detected using deformation-based morphometry. Neuroimage. 32(1):70-8. Epub 2006.

Woodward LJ et al. (2004) Can neurobehavioral examination predict the presence of cerebral injury in the very low birth weight infant? J Dev Behav Pediatr.25(5):326-34

Brown NC Neurobehavioural evaluation of the very preterm infant at term: relationships with concurrent advanced cerebral magnetic resonance imaging, and neurodevelopmental progress at two years of age PhD Melbourne 2006

Counsell SJ, Dyet L, Larkman DJ, Nunes RG, Boardman JP, Allsop JM, Fitzpatrick J, Srinivasan L, Cowan FM, Hajnal JV, Rutherford MA, Edwards AD. (2006) Assessment of connectivity in two year old infants who were born preterm using probabilistic MR tractography. NeuroImage Epub

Malamateniou C, Counsell SJ, Allsop J, Fitzpatrick J, Cowan F, Hajnal JV, Rutherford M. (2006) The effect of preterm birth on neonatal cerebral vasculature studied with Magnetic Resonance Angiography at 3 Tesla. Neuroimage. 32(3):1050-9

Krishnan ML, Dyet LE, Boardman JP, Kapellou O, Allsop JM, Cowan FM, AD Edwards, Rutherford MA, Counsell SJ. Relationship between white matter apparent diffusion coefficients in preterm infants at term equivalent age and developmental outcome at two years. Pediatrics. In press Marlow N, Wolke D, Bracewell MA, Samara M. (2005) EPICure Study Group. Neurologic and developmental disability at six years of age after extremely preterm birth. N Engl J Med. 352(1):9-19

Discussion.

The Bayley assessment has been adopted in a number of large studies, and it seems sensible to have consistency in such research. FC: It can be hard to complete the Bayley in these small babies, who lack the necessary endurance, and perhaps by reason of their prematurity are unable to give it the necessary attention. We and others have found a good correlation between the Griffiths assessment at 1-2 years and longer term outcomes.

The chair agreed in preferring the Griffiths, but regrets its lack of standardisation; the Bayley is useful in some circumstances.

RN: I attach importance to assessment between one and two years, when attention hyperactivity deficit disorder (ADHD) may be observed during play and in the reaction to adults. There are still no clear guidelines as to what we can do to help these children, and a lack of special nurseries and schools. Their parents need continuous support, and if attention deficit is to be addressed seriously they need a lot of training, so that their behaviour becomes consistent and appropriate for each child; a weekly visit with a therapist can never meet the case. But parents have much else to do, and the many who are in deprived and chaotic existences are incapable of providing such care.

JC: An equal number, affluent and well educated, whose pre-term babies are the results of treatment for infertility, are equally unaware of the nature of the care required. The quality of any professional services provided is very variable, the professionals themselves being in doubt as to how to proceed.

FC: Brain scanning by ultrasound is too little used, there is often little interest in it, and little if any quality control. One study showed that the diagnostic abilities of radiologists and neonatologists from the consultants down achieve less than 60% accuracy.

The chair enquired what is known and done about appropriate care for these babies while they are still in the NICU. There is little if any certain knowledge, but minimal intervention and oxygen saturations as low and unvarying as possible should be objectives, and at an interpersonal level they should be treated as human beings, with quiet times and the possibility for them to suck their thumbs or fists. The risks and benefits of analgesic medication and painful procedures have to be balanced.
JC: There are still no clear guidelines as to what we can best do to help these children, and there is a lack of special nurseries and schools. Parents need continuous support, and if attention deficit is to be addressed seriously they need a lot of training, so that their behaviour becomes consistent and appropriate for each child; a weekly visit with a therapist can never meet the case. But parents have much else to do, and the many who are in deprived and chaotic existences are incapable of providing such care.

Attempts are being made to make the NICU environment more like that of the uterus from which these babies have been snatched. Such are experiments with liquid environments, and simply wrapping the new born baby in clingfilm. The chair expressed her disappointment with the reports of trialled interventions, largely ineffective, both in the NICU and after discharge from hospital.

We have to admit ignorance of the effects of alterations to the intrauterine environment caused by drugs used in the treatment of infertility and by drug abuse. The chair could say that the reports comparing spontaneous premature births with those following infertility treatment have been mostly reassuring; these will have taken into account the effects of multiple birth, but small numbers limit the validity of such research.

Work in progress in a department of perinatal health psychology is indicating a benefit in parental self-efficacy (belief in the effectiveness of their interactions with their babies), when they had been given an activity intended to have a placebo effect. Other activities intended to be effective proved to be beneficial to the constructs self-esteem and quality of attachment, and it is important to follow up the parents to determine whether such benefits are long-lasting. They need to be provided with the necessary skills and continuity of input to sustain them.

FC: Health service priorities tend to ignore or not have the resources for this widespread need, their work being dominated by the fewer severely disabled children. The chair is involved at an early stage in research which should lead to better provision in this area.