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OBJECTIVES: To compare survival rates and age at death among very preterm infants in 10 national and regional neonatal networks. METHODS: A cohort study of very preterm infants, born between 24 and 29 weeks’ gestation and weighing RESULTS: Network populations differed with respect to rates of cesarean birth, exposure to antenatal steroids and birth in nontertiary hospitals. Network SRs for survival were highest in Japan (SR: 1.10; 99% confidence interval: 1.08–1.13) and lowest in Spain (SR: 0.88; 99% confidence interval: 0.85–0.90). The overall survival differed from 78% to 93% among networks, the difference being highest at 24 weeks’ gestation (range 35%–84%). Survival rates increased and differences between networks diminished with increasing gestational age (GA) (range 92%–98% at 29 weeks’ gestation); yet, relative differences in survival followed a similar pattern at all GAs. The median age at death varied from 4 days to 13 days across networks. CONCLUSIONS: The network ranking of survival rates for very preterm infants remained largely unchanged as GA increased; however, survival rates showed marked variations at lower GAs. The median age at death also varied among networks. These findings warrant further assessment of the representativeness of the study populations, organization of perinatal services, national guidelines, philosophy of care at extreme GAs, and resources used for decision-making.

OBJECTIVE:To study how the early crying behavior of preterm infants at term, 6 weeks, and 5 months of corrected age is related to later behavioral problems at age 3 and 4 years and parenting stress at 2 and 4 years.METHODS:The study group included 202 live-born, low birth weight infants (birth weight ≤1500 g) born from January 2001 through December 2006 at the Turku University Hospital, Finland. A Baby Day Diary was used to assess the preterm infants’ crying behavior at term, 6 weeks, and 5 months of corrected age. The children’s behavior was assessed using the Child Behavior Check List at 3 and 4 years old, and parenting stress was assessed by using the Parenting Stress Index when the child was 2 and 4 years old.RESULTS:The duration and frequency of crying bouts in infancy was associated with Child Behavior Check List scores at 4 years old and to both mothers’ and fathers’ stress when the child was 2 and 4 years old.CONCLUSIONS:Early excessive crying, especially if lasting up to 5 months of corrected age, is a clinically relevant signal in preterm infants because it may reflect infants’ regulatory problems and/or parenting stress. The crying behavior of preterm infants should be systematically inquired about at well-baby clinics.

OBJECTIVES: To study how antenatal growth affects cognitive outcome in very preterm infants and to determine whether there is an association between growth in any particular time period between birth and 5 years of age and cognitive outcome. Small for gestational age (SGA) and non-SGA infants were analyzed separately, because antenatal growth may affect postnatal growth. METHODS: Very low birth weight ( RESULTS: Growth in length and height was not associated with 5-year cognitive outcome. However, weight (r = 0.18, P = .04) and HC growth (r = 0.25, P = .01) between birth and 2 years of corrected age correlated to FSIQ in non-SGA children. In SGA children, HC growth (r = 0.33, P = .03) around term age correlated to FSIQ. CONCLUSIONS: Cognitive outcome was similar in SGA and non-SGA very preterm infants. Growth affected cognition positively in both subgroups, but the critical time period was different.

OBJECTIVE: The purpose was to explore whether poor parental psychological well-being is associated with behavioral problems of very low birth weight (VLBW, ≤1500 g) infants at 3 years of age. METHODS: In this prospective cohort study, 189 VLBW preterm infants born between January 2001 and December 2006 at the Turku University Hospital, Finland, were followed. Validated questionnaires (Beck Depression Inventory, Parenting Stress Index, and Sense of Coherence Scale) were mailed to the parents when their children were 2 years corrected age. A total of 140 parents evaluated the behavior of the child at 3 years by filling out the Child Behavior Checklist. RESULTS: There were significant associations between most of the measures of parental symptoms of depression, parenting stress, and sense of coherence and the behavioral outcome of the VLBW infants. The concomitant symptoms of both parents were associated with more problematic child behavior. CONCLUSIONS: Parents report more behavioral and emotional problems in VLBW children at age 3 if they themselves have had symptoms of depression, parenting stress, or weak sense of coherence 1 year earlier. The new finding of this study was to show the significance of the father’s psychological well-being on the behavioral development of a preterm child. * Abbreviations: BDI — : Beck Depression Inventory CBCL — : Child Behavior Checklist MDI — : Mental Development Index PSI — : Parenting Stress Index SOC — : sense of coherence SOC-13 — : Sense of Coherence Scale VLBW — : very low birth weight, ≤1500 g

OBJECTIVES: This study assessed the stability of cognitive outcomes of premature, very low birth weight (VLBW; ≤1500 g) children. METHODS: A regional cohort of 120 VLBW children born between 2001 and 2004 was followed up by using the Bayley Scales of Infant Development, Second Edition, at 2 years of corrected age and the Wechsler Preschool and Primary Scale of Intelligence–Revised at the age of 5 years. The Mental Development Index (MDI) and the full-scale IQ (FSIQ) were measured, respectively. A total of 168 randomly selected healthy term control children born in the same hospital were assessed for MDI and FSIQ. RESULTS: In the VLBW group, mean ± SD MDI was 101.2 ± 16.3 (range: 50–128), mean FSIQ was 99.3 ± 17.7 (range: 39–132), and the correlation between MDI and FSIQ was 0.563 (P < .0001). In the term group, mean MDI was 109.8 ± 11.7 (range: 54–128), mean FSIQ was 111.7 ± 14.5 (range: 73–150), and the correlation between MDI and FSIQ was 0.400 (P < .0001). Overall, 83% of those VLBW children who had significant delay (–2 SD or less) according to MDI had it also in FSIQ. Similarly, 87% of those children who were in the average range in MDI were within the average range in FSIQ as well. CONCLUSIONS: Good stability of cognitive development over time was found in VLBW children and in term children between the ages of 2 and 5 years. This conclusion stresses the value and clinical significance of early assessment at 2 years of corrected age. However, we also emphasize the importance of a long-term follow-up covering a detailed neuropsychological profile of these at-risk children.

OBJECTIVE: We assessed the effects of very preterm birth (gestational age METHODS: The study population consisted of 588 very preterm children and 176 term control subjects born in 2001–2002. Costs of hospitalizations, visits to health care professionals and therapists, and the use of other social welfare services were assessed during the fifth year of life. Hospital visits were derived from register data and other health care contacts, and the use of social welfare services were derived from parental reports. The effects of 6 prematurity-related morbidities (cerebral palsy [CP], seizure disorder, obstructive airway disease, hearing loss, visual disturbances or blindness, and other ophthalmologic problems) on the costs of health care were studied. RESULTS: The average health care costs during the fifth year of life were 749€ in the term control subjects, 1023€ in the very preterm children without morbidities, and 3265€ in those with morbidities. The costs of social welfare services and therapies exceeded the hospitalization costs in all groups. Among children who were born preterm, CP was associated with 5125€ higher costs, whereas later obstructive airway diseases increased the costs by 819€ compared with individuals without these morbidities. CONCLUSIONS: The health care costs during the fifth year of life in very preterm children with morbidities were 4.4-fold and in those without morbidities 1.4-fold compared with those of term control subjects. This emphasizes the importance of prevention of morbidities, especially CP, to reduce the long-term costs of prematurity.

OBJECTIVE: The objective of this study was to determine how the use of hospital resources during the first 3 years of life was associated with prematurity-related morbidity in very preterm infants (gestational age of METHODS: The study was a retrospective, national register study including all very preterm infants born alive in Finland between 2000 and 2003 (N = 2148). Infants who died before the age of 3 years (n = 264) or who had missing register data (n = 88) were excluded from the study. The relationship between 6 morbidity groups and the need for hospital care during the first 3 years of life was studied by using a negative binomial model. RESULTS: A total of 66.2% of the infants did not have any of the morbidities studied. Infants who were subsequently diagnosed as having cerebral palsy (6.1% of the study group), later obstructive airway disease (20.0%), hearing loss (2.5%), visual disturbances or blindness (3.8%), or other ophthalmologic problems (13.4%) had initial hospital stays that were a mean of 7, 8, 12, 17, and 3 days longer, respectively, than those for infants without these conditions. All morbidity groups were associated with increased numbers of hospital visits during either the second or third year of life, compared with infants without these morbidities. The need for hospitalizations and outpatient hospital care decreased with postnatal age for infants with later morbidities and for infants without later morbidities. CONCLUSIONS: Most very preterm infants born in Finland survived without severe morbidities and required relatively little hospital care after the initial discharge. However, those with later morbidities had a long initial length of stay and more readmissions and outpatient visits during the 3-year follow-up period.

Morbidity in preterm infants is reduced by a single course of corticosteroid treatment, administered prenatally. This randomized, blinded, placebo-controlled study was designed to show whether a single additional dose of 12-mg betamethasone, given with preterm birth imminent before 34 weeks' gestation and at least a week after the full treatment course, would further lower the risk of respiratory distress syndrome (RDS) and severe (grade 3 or 4) intraventricular hemorrhage (IVH). The initial course of therapy consisted of two 12-mg doses of betamethasone. Of 249 mothers enrolled in the study before it was discontinued, 125 were randomized to an additional 12-mg dose of betamethasone and 124 to placebo. All 159 infants born to actively treated mothers and all 167 whose mothers received placebo were born before 36 weeks' gestation. The mean gestational ages at delivery were 30.7 and 31.0 weeks, respectively. Additional steroid treatment did not influence the intact survival rate. In fact, the rate was lower than expected because the incidence of RDS, adjusted for gestational age, was higher than that in the general population. More infants in the steroid group required surfactant therapy. Posthoc analysis of data on 206 infants who were delivered within 1 to 24 hours indicated that the additional steroid dose tended to increase the risk of RDS and reduce the rate of intact survival. No differences were found between the steroid and placebo groups in mortality rates or rates of severe IVH. Six of the 11 infants who died were multiple births, and four of these were cases of twin-to-twin transfusion. Rather than augmenting the benefit of initial steroid therapy when preterm birth is imminent, an additional dose of steroid-administered just before preterm birth-may compromise respiratory adaptation. The findings of this study dictate caution in the use of repeat glucocorticoid therapy in high-risk pregnancies.

OBJECTIVE. Our goal was to investigate whether outcome in extremely low birth weight infants changes over time in Finland. PATIENTS AND METHODS. All infants with a birth weight RESULTS. A total of 529 and 511 extremely low birth weight infants were born during 1996–1997 and 1999–2000. No changes were detected in prenatal, perinatal, neonatal, and postneonatal mortality rates between the periods. The survival rates including stillborn infants were 40% and 44%. The incidence of respiratory distress syndrome and septicemia increased from 1996–1997 to 1999–2000 (75% vs 83% and 23% vs 31%). The overall incidence of intraventricular hemorrhage increased (29% vs 37%), but the incidence of intraventricular hemorrhage grades 3 through 4 did not (16% vs 17%). The rates of oxygen dependency at the age corresponding with 36 gestational weeks, retinopathy of prematurity stages 3 to 5, cerebral palsy, and severe visual impairment did not change. Mortality remained higher in 1 university hospital area during both periods compared with the other 4 areas, but no regional differences in morbidity were detected during the later period. CONCLUSIONS. No significant changes were detected in birth or mortality rate in extremely low birth weight infants born in Finland during the late 1990s, but some neonatal morbidities seemed to increase. Regional differences in mortality were detected in both cohorts. Repeated long-term follow-up studies on geographically defined very preterm infant cohorts are needed for establishing reliable outcome data of current perinatal care. Regional differences warrant thorough audits to assess causalities.

BACKGROUND: Previous studies have shown an association between prematurity and attention-deficit/hyperactivity disorder (ADHD). Results concerning late preterm infants are controversial, and studies examining fetal growth represented by weight for gestational age are scarce. Our objective was to examine the association between gestational age by each week of fetal maturity, weight for gestational age, and ADHD. METHODS: In this population-based study, 10 321 patients with ADHD, diagnosed according to the International Classification of Diseases and 38 355 controls individually matched for gender, date and place of birth, were identified from Finnish nationwide registers. Perinatal data were obtained from the Finnish Medical Birth Register. Conditional logistic regression was used to examine the association between gestational age, weight for gestational age, and ADHD after controlling for confounding factors. RESULTS: The risk of ADHD increased by each declining week of gestation. The associations were robust after adjusting for confounders. An elevated risk also was seen among late preterm and early term infants. As for fetal growth, the odds ratio showed a U-shaped curve with an increased risk seen when the weight for gestational age was 1 SD below and 2 SD above the mean. CONCLUSIONS: Our findings suggest that each gestational week has significance for child’s subsequent neurodevelopment and risk for ADHD. We also showed that poor fetal growth increased the risk of ADHD. This highlights the importance of taking into account both prematurity and poor fetal growth when planning the timing of birth as well as later follow-up and support policies.

OBJECTIVES. The objective of this study was to assess crying behavior during infancy in very preterm infants with or without brain injury.METHODS. A total of 125 very low birth weight infants survived during January 2001 to July 2004 in Turku University Hospital, Finland. They were categorized according to the most pathologic brain finding either in ultrasound or MRI. Baby Day Diary was used to assess crying behavior at term, 6 weeks, and 5 months of corrected age. The behavior of a group of term control infants (n = 49) was assessed at 5 months.RESULTS. Severe brain injuries in very low birth weight infants did not affect the duration of fussing or crying. In very low birth weight infants, brain injuries did not affect the frequency of fussing or crying bouts or the development of circadian rhythm in crying behavior. At 5 months of corrected age, fussing bouts were more frequent in very low birth weight infants compared with term control infants (6.4 per day vs 4.5 per day), and very low birth weight infants were held more (169 minutes [97] vs 130 minutes [69], respectively).CONCLUSIONS. This prospective study using a validated cry diary showed that brain injuries that are related to prematurity do not have major effects on crying behavior or development of circadian rhythm. Prematurity does not increase the duration but increases the frequency of fussing and crying at 5 months of corrected age compared with term control infants. It also seems that prematurity and brain pathology may increase caregiving activity in the form of holding.

Objective. Parents’ reports suggest that excessively crying or colicky infants sleep less compared with control subjects. The aim of this study was to determine the sleep-wake structure of excessively crying infants throughout a 24-hour cycle. Methods. A 24-hour sleep polygraphy study was conducted at home for 24 excessively crying infants and 23 control subjects at the age of 6 weeks. In addition, parental diaries were kept for 4 days. Results. In sleep polygraphy recordings, no major differences between study groups were observed in either the duration or the structure of the 24-hour sleep. In the diaries, the parents overestimated the amount of sleep in both study groups. The parents of the control infants overestimated the amount of sleep more than the parents of excessively crying infants (69.8 minutes [standard deviation: 79.3] compared with 27.1 minutes [standard deviation: 65.4], respectively). In excessively crying infants, the proportion of rapid eye movement sleep was higher during the 3-hour period from the beginning of the first long sleep in the evening and lower during the preceding 3-hour period compared with the control group. Conclusions. The results of this study suggest that diary-based studies are prone to be biased as the parents of the control infants are more likely to overestimate the amount of infant’s sleep and, therefore, report more sleep than the parents of the crying infants. Although no differences in the total amount of sleep or proportions of sleep stages were observed, excessively crying infants may be characterized by a disturbance that affects rapid eye movement and non–rapid eye movement sleep stage proportion during evening hours.

Objective. To study the effects of a critical illness and hospitalization of a newborn on family functioning and child behavior during the subsequent 12 years.Methods. With the use of a randomized stratified cluster sampling, a follow-up of 1443 pregnant women was started at early pregnancy. These pregnancies resulted in 1294 deliveries. A total of 170 infants were admitted to neonatal units and were classified according to their medical risk, and 1112 healthy-born infants were eligible for the control group. After excluding the children with disabilities at 3 years of age, 134 remained in the risk groups and 952 children remained in the control group. The follow-up examinations were performed at the ages of 3 and 9 months and at 3 and 12 years. The main outcome measures were parents’ subjective well-being and adjustment to the child, family functioning, and child’s behavioral problems.Results. The families with a critically ill newborn experienced more need for support and maladaptation during the first year after delivery. They reported more child behavior problems at 3 years, but no differences were found at 12 years of age. The families with a hospitalized, low-risk infant coped as well as the controls.Conclusions. A critical illness of a newborn had long-lasting effects on the family and child behavior. The hospitalization of a newborn with a low medical risk did not have any negative consequences on family or child behavior. This is encouraging for a large group of families that experience early separation from their newborn infant as a result of hospitalization.

OBJECTIVES. The aim of this study was to assess the relationship among the size of the lateral ventricles, head-circumference measure, and brain volumes. In addition, the association between ventricular dilatation and various brain lesions was defined. PATIENTS AND METHODS. A total of 257 preterm very low birth weight (≤1500 g) infants who met the inclusion criteria were born in Turku University Central Hospital between 2001 and 2006. A total of 209 (84.8%) of 218 survivors participated in the study. The measurements at term included the ventricular brain ratio, the widths of the frontal and occipital horns of the lateral ventricles by ultrasound, total and regional brain volumes by MRI, and head circumference. Brain lesions were defined by ultrasound at 3 to 5, 7 to 10, and 30 days of age monthly until discharge and by MRI and ultrasound at term. RESULTS. An abnormal ventricular brain ratio (>0.35), an increasing number of dilated ventricular horns, and smaller head circumference were significantly associated with smaller total brain tissue volume. The abnormal ventricular brain ratio and the increasing number of dilated ventricular horns in ultrasound associated with larger ventricular volumes in MRI, and a smaller head circumference was associated significantly with reduced regional brain tissue volumes. Brain lesions were more common in infants with ventriculomegaly. CONCLUSIONS. The ventricular brain ratio, widths of the lateral ventricular horns, and head circumference are appropriate measures for the estimation of both total and regional brain tissue volumes. Ventriculomegaly is strongly associated with brain lesions.

OBJECTIVE. Our goal was to test the hypothesis that the level of the delivery hospital affects 1-year mortality of very preterm infants in Finland. PATIENTS AND METHODS. This retrospective national medical birth-register study included 2291 very preterm infants (gestational age of RESULTS. Both the total 1-year mortality and the 1-year mortality of live-born infants were higher in level II hospitals compared with level III hospitals. Total mortality was higher in very preterm infants who were not born during office hours. In theory, delivery of all very preterm infants in level III instead of level II hospitals translates into an annual prevention of 69 of the 170 total deaths and prevention of 18 of the 45 deaths of live-born infants. CONCLUSIONS. Resources in neonatal intensive care should be increased, especially during non–office hours, to have an equally distributed service through the 24-hour day. More efficient regionalization of very preterm deliveries may improve 1-year survival of very preterm infants in Finland.

Objective. Increasing survival of extremely low birth weight (ELBW; birth weight Methods. Of all live-born ELBW infants (n = 351) who were delivered in the 2-year period 1996–1997 in Finland, 206 (59%) survived until the age of 5 years. Of these, 103 were born at Results. The rate of cognitive impairment in the ELBW survivors was 9%. The rate of cerebral palsy was 14% (19% of ELBW infants who were born at Conclusions. Only one fourth of the ELBW infants were classified as normally developed at age 5. The high rate of cognitive dysfunction suggests an increased risk for learning difficulties that needs to be evaluated at a later age. Extended follow-up should be the rule in outcome studies of ELBW infant cohorts to elucidate the impact of immaturity on school achievement and social behavior later in life.

Objective.To evaluate the effectiveness of infant massage compared with that of a crib vibrator in the treatment of infantile colic.Methods.Infants Results.At baseline, the mean amount of total crying was 3.6 (standard deviation: 1.4) hours/day in the massage group infants and 4.2 (2.0) hours/day in the vibrator group infants. The mean amount of colicky crying was 2.1 (standard deviation: 1.1) hours/day and 2.9 (1.5) hours/day, respectively. The mean number of daily intervention periods was 2.2 in both groups. Over the 4-week study, the amount of total and colicky crying decreased significantly in both intervention groups. The reduction in crying was similar in the study groups: total crying decreased by a mean 48% in the massage group and by 47% in the vibrator group, and colicky crying decreased by 64% and 52%, respectively. The amount of other crying (total crying minus colicky crying) remained stable in both groups over the intervention. Ninety-three percent of the parents in both groups reported that colic symptoms decreased over the 3-week intervention, and 61% of the parents in the massage group and 63% of the parents in the crib vibrator group perceived the 3-week intervention as colic reducing.Conclusions.Infant massage was comparable to the use of a crib vibrator in reducing crying in colicky infants. We suggest that the decrease of total and colicky crying in the present study reflects more the natural course of early infant crying and colic than a specific effect of the interventions.

Objective. To assess differences in family functioning or child-rearing attitudes within families with previously colicky infants and to assess whether the children differed in their behavior, development, or frequency of allergies. Study Design. A controlled, prospective study with infants (3 months to 3 years of age) and their families. Participants. Three hundred thirty-eight infants with and 866 infants without exhibited colic and their families. Methods. Questionnaires to mothers and nurses regarding infantile colic (3 months of age); questionnaires to mothers, fathers, and nurses regarding interactions within the family, parents' satisfaction with daily life, child caring, child behavior, and development (3 years old); the Denver Developmental Screening Test (parents filled out at home during the whole 3 years of infant development); the Achenbach Behavior Checklist for 2- to 3-year-old children (the 3-year visit at a well baby clinic). Results. The families of previously colicky infants demonstrated more dissatisfaction with the arrangements of daily family responsibilities and with the amount of both leisure time and shared activities. The children in the colic group had more sleeping problems and more frequent temper tantrums (at 3 years of age) than the control group. Conclusions. The families with colicky infants had more distress 3 years later. Families with colicky infants should be provided practical support in improving daily family functioning and child rearing. In addition, underlying problems in family relationships should be managed appropriately.