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Long-term follow-up of very low birthweight children: A prospective study from the southeast region of Sweden
Linköping University, Faculty of Health Sciences. Linköping University, Department of Clinical and Experimental Medicine, Pediatrics .
2008 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Background: The survival rates for very low birthweight (VLBW; birthweight ≤1500 g) children are increasing, but they run a greater risk than controls of developing neurosensory disabilities and other functional problems during childhood. However, there is a great need for more knowledge regarding long-term outcome to adulthood in VLBW subjects.

Aims: To evaluate long-term outcomes in a regional cohort of VLBW children born in 1987-88 regarding hospital readmissions, morbidity, neurological conditions, cognitive function, reading skills, school achievements, behaviour, growth, general health, and social functioning in relation to gender, neonatal risk factors, disability and Magnetic Resonance Imaging (MRI) findings.

Study design: Prospective longitudinal case-controlled long-term regional follow-up.

Material and Methods: A total of 86 (80.4%) children (47 boys out of 60 and 39 girls out of 47 live-borns) survived the neonatal period and were recruited to the follow-up study. A total of 86 term controls (45 boys and 41 girls) were included from the newborn period. Readmissions, hospital diagnoses, need of habilitation and child psychiatric care were checked in registers to 15 years of age. The VLBW children were enrolled in the follow-up study at 40 weeks gestational age and at 4, 9, and 15 years of age in assessing neurological conditions. At 15 years of age, the groups were assessed in cognition (WISC III), reading skills, school outcome, behaviour, vision and growth. Fifty-nine (69%) VLBW children were examined using cerebral MRI. Physical and mental health, weight and height, education, and socio-economic situation were assessed at 20 years of age in 77/85 VLBW and 69/84 control subjects by means of postal questionnaires.

Results: VLBW boys had three times more readmissions compared with control boys (p=0.003). Gestational age below 30 weeks, birthweight less than 1000 g, and mechanical ventilation were neonatal risk factors for readmissions. Five (5.8%) children had moderate/severe cerebral palsy, 5 (5.8%) had attention deficit hyperactivity disorder, and 1 was blind due to retinopathy of prematurity.

VLBW children were inferior in neurological function in comparison with controls at 40 weeks of gestational age and 4 and 15 years of age. Fourteen of 56 (25%) VLBW children without overt disability had abnormal MRI findings. Mechanical and/or intraventricular haemorrhages (IVH) were significantly related to less favourable neurological outcome. VLBW children performed significantly lower than their controls on a few reading variables and on WISC III. Half of them had IQ lower than 85. Ten VLBW children with IQ < 70 had not been clinically identified earlier and a majority of these children attended mainstream school. Small head circumference correlated with low IQ. Mechanical ventilation and IVH correlated with lower IQ and poorer reading skills. At 20 years of age, the VLBW subjects did not differ significantly from the controls in self-perceived health, education, occupation and way of living.

Conclusions: Most VLBW subjects were without major health problems up to 20 years of age and had attended mainstream schools. The presence of IVH and mechanical ventilation during the neonatal period negatively influenced health outcomes. VLBW children without overt neurological disability performed somewhat less well in neurological examinations in comparison with controls. VLBW children achieved poorer results in cognitive tests, but reading skills made a catch-up to 15 years of age. A majority of VLBW subjects managed transition to adulthood similar to that of controls.

Abstract [sv]

Bakgrund: Överlevnaden för nyfödda barn med mycket låg födelsevikt (1500 g eller lägre; VLBW) har ökat avsevärt under de senaste årtionden och man finner nu att ca 90 % av barnen skrivs ut från neonatalavdelningar. Risken för cerebral pares (CP) har visat sig vara ökad jämfört med barn födda i fullgången tid. Studier visade att VLBW-barn som kommit upp i skolåldern hade högre frekvens av läs- och skrivsvårigheter, oftare behövde specialundervisning, samt hade högre grad av beteendeproblem jämfört med klasskamrater.

Uppföljningsstudier var tidigare mestadels gjorda på populationer från större sjukhus, kontrollgrupp saknades eller inlemmades efter flera år, uppföljningstiden var kort och flera viktiga områden av barnets utveckling var ofullständigt undersökta. I Sverige saknades en studie med långtidsuppföljning av VLBW-barn födda under en tidsperiod då alltfler barn hade börjat erhålla andningshjälp med respirator. Socioekonomiska förhållanden i Sverige kan inte heller helt och hållet jämföras med flertalet andra länder.

Syfte: Den här avhandlingens syfte var att studera hur det går för VLBW-barn upp till 15 års ålder avseende sjuklighet, motoriska funktioner, kognitiva funktioner, skolprestationer och beteende, samt vid 20 års ålder avseende hälsotillstånd, sysselsättning och boende. Undersökningsresultaten relaterades till nyföddhetsfaktorer och fynd vid magnet resonans-undersökning (MRI) av hjärnan vid 15 års ålder.

Material och metoder: 86 överlevande VLBW-barn samt 86 barn födda i fullgången tid från 1/2 1987 till 30/4 1988 i sydöstra sjukvårdsregionen (Jönköpings, Kalmar och Östergötlands län) har ingått i studien. Uppgift om antalet sjukhusinläggningar och huvuddiagnos inhämtades från Slutenvårdsregistret, Epidemiologiskt centrum, Socialstyrelsen. Uppgifter om antalet barn med CP, ADHD, mental retardation och barnpsykiatriskt vårdbehov inhämtades från habiliteringscentraler och barnpsykiatriska kliniker i regionen. Information om skolbetyg från 9:e årskursen och skolgång inhämtades från kommunerna. Neurologiska och motoriska undersökningar utfördes på barn utan synligt handikapp enligt särskilda protokoll såväl neonatalt som vid 4, 9 och 15 års ålder. Vikt och längd, kognitiv test (WISC III), lästester och MRI undersökning (enbart VLBW-barn) gjordes vid 15 års ålder. Barn och föräldrar fick fylla i formulär om beteende. Vid 20 års ålder (december 2007) fick deltagarna tre frågeformulär: ett studiespecifikt med frågor om hälsa, vikt och längd, användning av tobak och alkohol, gymnasiestudier, nuvarande sysselsättning och boende; SF-36, som belyser fysisk kapacitet, allmän hälsa, vitalitet och psykiskt välbefinnande; samt KASAM (känsla av sammanhang), som belyser hur man upplever sitt eget sätt att fungera, uppdelat i begriplighet, hanterbarhet och meningsfullhet.

Resultat: VLBW-barn (mest pojkar) vårdades oftare på sjukhus under första levnadsåren jämfört med kontroller. Infektioner och neurologiska sjukdomar dominerade för både VLBW-pojkar och -flickor. Fem (5.8 %) VLBW-barn hade måttlig/svår CP och fem hade ADHD. Hjärnblödning eller respiratorbehandling under nyföddhetsperioden var de faktorer som oftast var relaterade till sämre hälsotillstånd. Det var ingen skillnad i antal barn med behov av barnpsykiatrisk vård mellan grupperna. Det var ingen skillnad i summering av 9 slutbetyg mellan grupperna, men VLBW-pojkar hade lägre betyg i matematik och teknologi jämfört med sina kontroller. VLBW-barnen var lättare och kortare, men skillnaderna var störst mellan VLBW-flickor och deras kontroller. VLBW-barnen (fr.a. pojkarna) presterade lägre i neurologiska undersökningar, samt i kognitiva test. Tio av tolv av barnen som hade IQ under 70 var tidigare inte kända. Det fanns skillnader mellan grupperna i lästester, men signifikant enbart i ett test. Jämfört med lästester vid 9 års ålder hade VLBW-barnen gjort en upphämtning. Det framkom inga skillnader i beteende mellan grupperna, men VLBW-flickor uppgav färre beteendeproblem än sina kontroller. Vid 20 års ålder framkom inga skillnader i självuppskattad hälsa eller behov av vårdkontakter och läkemedel mellan grupperna. Tobaksanvändning var lika i grupperna, men fler i VLBW-gruppen var icke-användare av alkohol. Det var ingen signifikant skillnad i andel som gått ut gymnasiet, nuvarande sysselsättning eller boendeform mellan grupperna. Det var inga signifikanta skillnader i resultat på SF-36 och KASAM mellan grupperna.

Konklusion: Hjärnblödning och respiratoranvändning under nyföddhetsperioden var de faktorer som hade störst inverkan på VLBW-barnens hälsotillstånd upp till 20 års ålder. CP och ADHD förekom hos relativt få, men lågt IQ var vanligt. VLBW-pojkar hade större sjukvårdsbehov, presterade lägre i neurologiska test och hade lägre skolbetyg än sina kontroller. VLBW-gruppen skilde sig inte från kontroll-gruppen avseende beteendeproblem. Självuppskattad hälsa vid 20 år skilde sig inte mellan grupperna. Särskilda uppföljningsprogram för VLBW-barn är nödvändigt där kognitiva tester ingår vilka bör utföras före skolstart.

Place, publisher, year, edition, pages
Linköping: Linköping University Electronic Press , 2008. , 93 p.
Series
Linköping University Medical Dissertations, ISSN 0345-0082 ; 1076
Keyword [en]
Very low birthweight infants, Follow-up studies, Adolescence, Gender, Neonatal risk factors, Magnetic Resonance Imaging, Cognitive function, School performance, Health, Quality of Life
National Category
Pediatrics
Identifiers
URN: urn:nbn:se:liu:diva-15492ISBN: 978-91-7393-812-9 (print)OAI: oai:DiVA.org:liu-15492DiVA: diva2:117356
Public defence
2008-10-10, Aulan, Länssjukhuset Ryhov, Länssjukhuset Ryhov, Jönköping, 13:00 (Swedish)
Opponent
Supervisors
Available from: 2008-11-21 Created: 2008-11-12 Last updated: 2009-08-21Bibliographically approved
List of papers
1. Hospital readmissions and morbidity in a fifteen-year follow-up of very low birthweight children in Southeast Sweden
Open this publication in new window or tab >>Hospital readmissions and morbidity in a fifteen-year follow-up of very low birthweight children in Southeast Sweden
2007 (English)In: Acta Paediatrica, ISSN 0803-5253, E-ISSN 1651-2227, Vol. 96, no 4, 499-505 p.Article in journal (Refereed) Published
Abstract [en]

Aim: To study the effect of very low birthweight on hospital care and morbidity, and their relationship to gender, birthweight, and neonatal complications.

Methods: 85 very low birthweight (VLBW; ≤1500 g) children and term controls born in 1987-1988 in south-east region of Sweden were checked in registers regarding readmissions and diagnoses, need for habilitation and child psychiatric care up to 15 years of age. Ophthalmological examinations were made at age 4 in 64 of VLBW and 61 of control children, and at age 15 in 59 of VLBW and 55 of control children.

Results: VLBW boys had three times more readmissions compared with normal weight control boys (p=0.003). Neonatal risk factors for readmissions were gestational age under 30 weeks (OR 3.1), birthweight less than 1000 g (OR 4.6), mechanical ventilation (OR 9.5), and more than 60 days’ stay in neonatal ward (OR 5.0). A minority of VLBW children had an impairment/handicap such as cerebral palsy (CP) in five (5.9 %) children, attention deficit hyperactivity disorders (ADHD) in five children, and blindness due to retinopathy of prematurity in one child. One child in the control group had ADHD. At the 15-year examination median visual acuity in the best eye was better in the control group (1.6) than in the VLBW group (1.3) (p=0.009). 32% of VLBW children and 11% of controls had latent or manifest strabismus (p=0.007).

Conclusion: Risk factors for readmissions were gender, low gestational age, birthweight <1000 g or mechanical ventilation. A minority of VLBW children had a handicap that influenced their daily life activities at 15 years of age.

Place, publisher, year, edition, pages
Wiley InterScience, 2007
Keyword
Follow-up studies, Gender, Hospital readmission, Morbidity, Very low birth weight
National Category
Pediatrics
Identifiers
urn:nbn:se:liu:diva-15483 (URN)10.1111/j.1651-2227.2007.00183.x (DOI)
Available from: 2008-12-04 Created: 2008-11-11 Last updated: 2017-12-14Bibliographically approved
2. A fifteen-year follow-up of neurological conditions in VLBW children without overt disability: Relation to gender, neonatal risk factors, and end stage MRI findings
Open this publication in new window or tab >>A fifteen-year follow-up of neurological conditions in VLBW children without overt disability: Relation to gender, neonatal risk factors, and end stage MRI findings
2008 (English)In: Early Human Development, ISSN 0378-3782, E-ISSN 1872-6232, Vol. 84, no 5, 343-349 p.Article in journal (Refereed) Published
Abstract [en]

Background: Very low birthweight (VLBW; birth weight ≤ 1500 g) children run a greater risk than controls of developing neurosensory disabilities, but also minor neurological disturbances.

Aims: To assess neurological status from the neonatal period up to fifteen years of age in VLBW children without overt neurological disability in relation to gender, neonatal risk factors, and Magnetic Resonance Imaging (MRI) findings of the brain.

Study design: A population based follow-up study of VLBW children and their controls.

Subjects: Eighty VLBW children without overt disability, in a cohort of 86 surviving VLBW children, were enrolled in a follow-up study at 40 weeks gestational age and at 4, 9, and 15 years of age. 56 VLBW children were examined with cerebral MRI at 15 years of age.

Outcome measures: Neurological test scores. MRI findings, principally white matter damage (WMD).

Results: VLBW children were inferior in neurological assessments in comparison with controls at 40 weeks gestational age and 4 and 15 years of age. VLBW girls did not differ from their controls at 9 and 15 years. Fourteen of 56 (25%) VLBW children had abnormal MRI findings and 13 were evaluated as mild WMD. Children with WMD did not differ in neurological outcome from those without WMD at any examination. Mechanical ventilation and/or intraventricular haemorrhage (IVH) during the neonatal period were significantly related to less a favourable outcome at follow-up examinations.

Conclusion: A cohort of VLBW children without overt neurological disability had a poorer neurological condition up to adolescence in comparison with controls. A quarter of the VLBW children had mild WMD but without relation to the neurological functions. Mechanical ventilation and IVH were related to poorer neurological outcome.

Place, publisher, year, edition, pages
Elsevier, 2008
Keyword
Very low birthweight infants, Follow-up study, Magnetic Resonance Imaging, Neurological function, Neonatal risk factors
National Category
Pediatrics
Identifiers
urn:nbn:se:liu:diva-15485 (URN)10.1016/j.earlhumdev.2007.09.013 (DOI)
Available from: 2008-12-04 Created: 2008-11-11 Last updated: 2017-12-14Bibliographically approved
3. Academic achievement, behavioural outcomes and MRI findings at 15 years of age in very low birthweight children
Open this publication in new window or tab >>Academic achievement, behavioural outcomes and MRI findings at 15 years of age in very low birthweight children
Show others...
2008 (English)In: Acta Paediatrica, ISSN 0803-5253, E-ISSN 1651-2227, Vol. 97, no 10, 1426-1432 p.Article in journal (Refereed) Published
Abstract [en]

Aim: To assess cognitive, academic, and behavioural functions in 15-year-old very low birthweight (VLBW) children and relate results to gender, neonatal risk factors, growth, and Magnetic Resonance Imaging (MRI) findings.

Methods: 61/86 VLBW children and 57/86 term controls born in the south-east region of Sweden were assessed regarding cognition (WISC III), school outcome, behaviour, and growth. VLBW children were examined using cerebral MRI.

Results: VLBW children performed significantly lower than their term controls on WISC III and 49% had IQ lower than 85. Ten VLBW children with IQ <70 had not been clinically identified earlier and a majority of these children attended mainstream school. VLBW girls had significantly lower total problems scores. Using MRI, white matter damage (WMD) was detected in 16 (27%) children. VLBW boys with WMD had significantly lower IQ than those without. Small occipito-frontal circumference correlated with low IQ. Mechanical ventilation and intraventricular haemorrhage (IVH) showed significant correlations with lower IQ and reading skills.

Conclusion: VLBW children achieved poorer results compared with their controls in cognitive tests. Mechanical ventilation and IVH were related to poorer academic outcome. Many of the children with low IQ had not been identified earlier. Therefore, we recommend that VLBW children undergo an IQ test before beginning school in order to receive adequate support.

Keyword
Cognitive function, MRI findings, Neonatal risk factors, School performance, Very low birthweight infants
National Category
Pediatrics
Identifiers
urn:nbn:se:liu:diva-15486 (URN)10.1111/j.1651-2227.2008.00925.x (DOI)
Available from: 2008-12-04 Created: 2008-11-11 Last updated: 2017-12-14Bibliographically approved
4. Health, quality of life, educational level, and occupation in early adulthood in very low birthweight subjects in south-east Sweden
Open this publication in new window or tab >>Health, quality of life, educational level, and occupation in early adulthood in very low birthweight subjects in south-east Sweden
(English)Manuscript (Other academic)
Abstract [en]

Objectives: To study health, quality of life, educational level and occupation in very low birthweight children (VLBW; ≤1500 g) in early adulthood and relationship to neonatal risk factors and handicap.

Design: Prospective long-term follow-up study.

Setting: Regional cohort.

Participants: Twenty-year-old VLBW subjects (n=77) of all surviving VLBW children (n=86) and 69/86 term controls born in 1987-1988 in the south-east of Sweden.

Outcome Measures: Postal questionnaires: 1. A study-specific form with questions about health, tobacco and alcohol use, weight and height, education, occupation and socio-economic situation. 2. Medical Outcomes Study, Short Form (SF-36). 3. Sense of Coherence (SOC).

Results: VLBW subjects did not differ significantly from the controls in self-perceived health, use of tobacco, education, occupation and way of living, or scoring on SF-36 and SOC. Sixteen had cerebral palsy, attention deficit hyperactivity disorder, or isolated mental retardation, and those differed significantly from controls on SF-36 in physical functioning and physical health score, but not on SOC. VLBW subjects were significantly lighter and shorter than their controls. Extremely low birthweight (ELBW), bronchopulmonary dysplasia and intraventricular haemorrhage were significantly associated with poorer scores on physical functioning and physical health score.

Conclusions: A majority of VLBW subjects were healthy at 20 years of age and managed transition to adulthood similar to controls. A minority had handicaps that influenced their physical function. ELBW and severe neonatal complications were associated with poorer self-perceived physical health in early adulthood.

Keyword
Adult, Health, Infant Very Low Birth Weight, Follow-Up Studies, Quality of Life
National Category
Pediatrics
Identifiers
urn:nbn:se:liu:diva-15487 (URN)
Available from: 2008-12-04 Created: 2008-11-11 Last updated: 2010-01-14Bibliographically approved

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