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Assessment and Evaluation of the High Risk Neonate: The NICU Network Neurobehavioral Scale
Published on: August 25, 2014
Increased survival and deteriorating developmental outcome in 23 to 25 week old gestation infants, 1990-4 compared
H C Emsley1, S P Wardle, D G Sims
1Department of Child Health, University of Manchester, St Mary's Hospital.
Insights
Improved survival for extremely preterm infants (23-25 weeks gestation) was linked to increased rates of childhood disability, primarily from vision impairments like retinopathy of prematurity, myopia, and squint, not cerebral palsy.
Area of Science:
- Neonatal Medicine
- Developmental Pediatrics
- Ophthalmology
Background:
- Improved survival rates for extremely preterm infants (23-25 weeks gestation) have been observed over recent decades.
- However, the impact of enhanced survival on the incidence and types of childhood disability requires ongoing investigation.
Purpose of the Study:
- To determine if increased survival in extremely preterm infants (23-25 weeks gestation) over an 11-year period correlated with changes in childhood disability rates.
- To identify specific types of disabilities contributing to any observed changes.
Main Methods:
- A retrospective cohort study of 192 infants born at 23-25 weeks gestation between 1984 and 1994.
- Infants were divided into two cohorts (1984-1989 and 1990-1994).
- Data included obstetric and neonatal variables, Clinical Risk Index for Babies (CRIB) scores, cranial ultrasound findings, and neurodevelopmental assessments.
Main Results:
- Survival to discharge significantly increased from 27% to 42% between the two cohorts.
- The rate of disability among survivors also increased significantly from 38% to 68%, with mild disabilities being most common.
- Increases in blindness (retinopathy of prematurity), myopia, and squint were noted, while cerebral palsy rates remained stable.
Conclusions:
- The rise in childhood disability among survivors of extreme prematurity was primarily driven by visual impairments (retinopathy, myopia, squint), not cerebral palsy.
- High CRIB scores were strongly associated with both mortality and disability.
- Recommendations include implementing regular retinal examinations and access to retinal ablation services for all neonatal units caring for extremely preterm infants.
Aims:
To assess whether changes in survival over time in infants of 23 to 25 weeks of gestational age were accompanied by changes in the incidence of disability in childhood during an 11 year period.
Methods:
Obstetric and neonatal variables having the strongest association with both survival to discharge from a regional neonatal medical unit and neurodevelopmental disability in 192 infants of 23 to 25 weeks of gestation, born in 1984 to 1994, were studied as a group and in two cohorts (1984 to 1989 n = 96 and 1990 to 1994 n = 96). The data collected included CRIB (clinical risk index for babies) scores and cranial ultrasound scan findings. The children were followed up at outpatient clinics.
Results:
Between 1984 and 1989 (cohort 1) and 1990 and 1994 (cohort 2) the rate of survival to discharge increased significantly from 27% to 42% and the rate of disability in survivors increased from 38% to 68%; most of this increase was in mild disability. The proportions of survivors with cerebral palsy did not alter significantly (21% vs 18%), but more survivors with blindness due to retinopathy of prematurity (4% vs 18%), myopia (4% vs 15%) and squints (8% vs 13%) contributed to the increased rate of disability. Clinically significant cranial ultrasound findings and a high CRIB score were strongly associated with death. A high CRIB score was most strongly associated with disability.
Conclusions:
The rise in disability with improved survival was not due to cerebral palsy; rather the main contributors were blindness due to retinopathy, myopia, and squint. The causes of these disabilities seem to be linked to high CRIB scores. A system of regular and skilled retinal examination and access to facilities for retinal ablation should be in place in all neonatal units which undertake the care of such extremely preterm infants.
