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Chronic physiologic instability is associated with neurodevelopmental morbidity at one and two years in extremely
1Division of Neonatology, Department of Pediatrics, University of Minnesota and Children's Hospitals and Clinics-St Paul, St Paul, Minnesota, USA.
Insights
Physiologic instability in extremely premature infants, measured by the Score for Neonatal Acute Physiology (SNAP), is linked to poorer neurodevelopmental outcomes. These findings highlight the importance of monitoring infant stability for long-term health.
Area of Science:
- Neonatology
- Neurodevelopmental Pediatrics
- Pediatric Critical Care
Background:
- Premature infants face significant risks for neurodevelopmental morbidity.
- Physiologic instability during the neonatal period is a potential contributor to long-term adverse outcomes.
- The Score for Neonatal Acute Physiology (SNAP) quantifies daily physiologic instability in neonates.
Purpose of the Study:
- To investigate the association between chronic physiologic instability (cumulative daily SNAP scores) and neurodevelopmental outcomes in extremely premature infants.
- To assess neurodevelopmental outcomes at 1 year and 2 to 3 years of age.
- To determine if physiologic instability independently affects neurodevelopment, beyond factors like intracranial abnormalities and gestational age.
Main Methods:
- Retrospective study of extremely premature infants (<=30 weeks gestational age).
- Cumulative daily SNAP scores calculated for the NICU stay.
- Neurodevelopmental assessments included Bayley Scales (MDI, PDI) at 1 year and 2-3 years, and Receptive-Expressive Emergent Language Scale (REEL) at 2-3 years.
- Infants stratified into quartiles based on SNAP scores; ANOVA and multiple regression analyses used.
Main Results:
- Infants with the highest SNAP scores (>75th percentile) showed significantly lower Mental Development Index (MDI) and Psychomotor Development Index (PDI) scores at 1 year and 2-3 years.
- Sixty-seven percent of infants with the highest instability experienced neurodevelopmental abnormalities by 2-3 years.
- Higher cumulative SNAP scores, intraventricular hemorrhage (IVH) scores, and gestational age (GA) were associated with lower MDI and PDI scores at 1 year.
- By 2-3 years, only higher cumulative SNAP scores remained significantly associated with lower MDI and PDI scores.
- Language development was linked to early weight changes and hypotension scores, but not consistently to SNAP scores.
Conclusions:
- Prolonged physiologic instability in extremely premature infants is associated with adverse neurodevelopmental outcomes up to 2-3 years of age.
- This association appears independent of intracranial abnormalities and gestational age.
- The findings underscore the importance of optimizing physiologic stability in the NICU to improve long-term neurodevelopmental trajectories.
Objective:
The objective of this study was to evaluate the relationships between chronic physiologic instability, as assessed by the cumulative daily Score for Neonatal Acute Physiology (SNAP), and neurodevelopmental morbidity in premature infants at 1 year and at 2 to 3 years of age.
Design:
The subjects of this retrospective study were extremely premature (75th percentile). MDI, PDI, and REEL scores were compared for the three groups using analysis of variance. To evaluate the relative contributions of physiologic stability, intracranial abnormalities, GA, and early postnatal nutritional intakes, multiple regression analyses were performed using cumulative SNAP score, an intraventricular hemorrhage (IVH) score (incorporating IVH and periventricular leukomalacia), GA, and a weight-change score for the first month as independent variables, and MDI, PDI, and REEL quotients as dependent variables. Regression analyses were repeated, with cumulative SNAP subscores for oxygenation, hypotension, acidosis, and hypoxia/ischemia included with IVH score, GA, and first month weight z score change as independent variables, and MDI, PDI, and REEL quotients as dependent variables.
Results:
The infants with the highest degree of physiologic instability (cumulative SNAP scores greater than the 75th percentile) had significantly lower MDI scores at 1 year of age and lower PDI scores at 1 year and at 2 to 3 years of age than did infants who were more physiologically stable. Sixty-seven percent of infants with cumulative SNAP scores greater than the 75th percentile had neurodevelopmental abnormalities at 2 to 3 years of age (cerebral palsy or delayed mental, motor, or language development). Using multiple regression analyses, higher cumulative SNAP scores, IVH scores, and GA were associated with lower 1-year MDI scores. Higher cumulative SNAP scores and IVH scores were associated with lower 1-year PDI scores. By 2 years, only higher cumulative SNAP scores were significantly associated with lower MDI and PDI scores. With respect to language development, only lower weight-change scores over the first month were significantly associated with poorer receptive language development. Lower weight-change scores over the first month and higher hypotension scores were significantly associated with poorer expressive language development. In the secondary regression analyses, higher IVH score, higher cumulative oxygenation scores, and higher hypoxia/ischemia scores all were significantly associated with lower 1-year MDI scores. By 2 to 3 years of age, only higher oxygenation scores were significantly associated with lower MDI scores.
Conclusions:
Prolonged physiologic instability was associated with deleterious neurodevelopmental consequences for extremely premature infants through 2 to 3 years of age, independent of effects of intracranial abnormalities and GA.