School-age effects of the newborn individualized developmental care and assessment program for preterm infants with intrauterine growth restriction: preliminary findings

Gloria McAnulty, Frank H Duffy, Sandra Kosta, Neil I Weisenfeld, Simon K Warfield, Samantha C Butler, Moona Alidoost, Jane Holmes Bernstein, Richard Robertson, David Zurakowski, Heidelise Als, Gloria McAnulty, Frank H Duffy, Sandra Kosta, Neil I Weisenfeld, Simon K Warfield, Samantha C Butler, Moona Alidoost, Jane Holmes Bernstein, Richard Robertson, David Zurakowski, Heidelise Als

Abstract

Background: The experience in the newborn intensive care nursery results in premature infants' neurobehavioral and neurophysiological dysfunction and poorer brain structure. Preterms with severe intrauterine growth restriction are doubly jeopardized given their compromised brains. The Newborn Individualized Developmental Care and Assessment Program improved outcome at early school-age for preterms with appropriate intrauterine growth. It also showed effectiveness to nine months for preterms with intrauterine growth restriction. The current study tested effectiveness into school-age for preterms with intrauterine growth restriction regarding executive function (EF), electrophysiology (EEG) and neurostructure (MRI).

Methods: Twenty-three 9-year-old former growth-restricted preterms, randomized at birth to standard care (14 controls) or to the Newborn Individualized Developmental Care and Assessment Program (9 experimentals) were assessed with standardized measures of cognition, achievement, executive function, electroencephalography, and magnetic resonance imaging. The participating children were comparable to those lost to follow-up, and the controls to the experimentals, in terms of newborn background health and demographics. All outcome measures were corrected for mother's intelligence. Analysis techniques included two-group analysis of variance and stepwise discriminate analysis for the outcome measures, Wilks' lambda and jackknifed classification to ascertain two-group classification success per and across domains; canonical correlation analysis to explore relationships among neuropsychological, electrophysiological and neurostructural domains at school-age, and from the newborn period to school-age.

Results: Controls and experimentals were comparable in age at testing, anthropometric and health parameters, and in cognitive and achievement scores. Experimentals scored better in executive function, spectral coherence, and cerebellar volumes. Furthermore, executive function, spectral coherence and brain structural measures discriminated controls from experimentals. Executive function correlated with coherence and brain structure measures, and with newborn-period neurobehavioral assessment.

Conclusion: The intervention in the intensive care nursery improved executive function as well as spectral coherence between occipital and frontal as well as parietal regions. The experimentals' cerebella were significantly larger than the controls'. These results, while preliminary, point to the possibility of long-term brain improvement even of intrauterine growth compromised preterms if individualized intervention begins with admission to the NICU and extends throughout transition home. Larger sample replications are required in order to confirm these results.

Clinical trial registration: The study is registered as a clinical trial. The trial registration number is NCT00914108.

Figures

Figure 1
Figure 1
Consort flow chart.
Figure 2
Figure 2
Standard EEG electrode names and positions. Head in vertex view, nose above, left ear to left. EEG electrodes: Z: Midline: FZ: Midline Frontal; CZ: Midline Central; PZ: Midline Parietal; OZ: Midline Occipital. Even numbers, right hemisphere locations; odd numbers, left hemisphere locations: Fp: Frontopolar; F: Frontal; C: Central; T: Temporal; P: Parietal; O: Occipital. The standard 19, 10–20 electrodes are shown as black circles. An additional subset of 17, 10–10 electrodes are shown as open circles.
Figure 3
Figure 3
3D rendering of parcellation of a 9-year-old child’s brain from MRI. The surface model is depicted on top of a mid-sagittal slice from the T1-weighted MRI. Comparison of regional tissue volumes across subjects can be employed to indicate localized structural differences.
Figure 4
Figure 4
Demonstration of T1-weighted MRI tissue segmentation combined with parcellation of a 9-year-old child’s brain. Axial slice on the left; corresponding combined tissue segmentation/parcellation on the right.
Figure 5
Figure 5
Rey-Osterrieth complex figure. The figure represents sample drawings from two study children, one from the Control group, a 9 year 11 month old born at 29w GA; and one from the Experimental group, a 9 year 6 month old born at 32w GA. The conditions displayed are from left to right: Copy, Immediate Recall and Delayed Recall.
Figure 6
Figure 6
EEG spectral coherence factors at school-age, control (C) (n =12), experimental (E) (n = 9). Head shown in vertex view, nose above, left ear to left. EEG frequency and coherence electrodes shown above head. Arrow color illustrates experimental group coherence; green = decreased, red = increased.
Figure 7
Figure 7
Distribution of right and left cerebellar tissue volumes by group. The figure represents a scatter plot of the control (n = 11) and the experimental (n = 7) groups’ distributions of right and left cerebellar tissue volumes expressed as percentage of total parenchyma.

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