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Objective: To determine if very low birthweight children followed with ease differ in any perinatal or sociodemographic characteristics, or outcomes, compared with children followed with more difficulty. Methodology: Consecutive children of birthweight < 1000 g or with gestational ages < 28 weeks born in 1991 (n = 51) or of birthweight < 1500 g born in 1992 (n = 166) at the Royal Women’s Hospital, Melbourne, surviving to 5 years of age, were assessed at 5 years of age, corrected for prematurity. Those who attended on the first mutually agreed appointment without substantial reluctance were considered to have been followed with ease. The remainder were considered to have been followed with difficulty. Outcomes included impairments such as cerebral palsy, blindness, deafness, and low IQ. Children had a disability if they had any of cerebral palsy, blindness, deafness requiring amplification, or an IQ more than 1 SD below the mean. Results: Of the 217 survivors, 204 (94%) were assessed fully at 5 years of age. Of the 204 children assessed, 153 (75%) were followed with ease, and 51 (25%) with difficulty. Of data available in the perinatal period, significantly fewer children followed with more difficulty came from intact families, and more of their mothers had fewer than 12 years of schooling. More children followed with difficulty had a disability (41% compared with 19%), as they predominantly had lower IQ scores (mean difference in IQ – 12.7, 95% confidence interval – 18.0, – 7.4). The association between difficulty of assessment and both higher rates of disability and lower IQ scores remained after adjustment for significant perinatal and sociodemographic variables. Conclusions: Children followed with difficulty can partly be recognized on several sociodemographic characteristics in the perinatal period, and have substantially worse sensorineural outcomes than those followed with ease. In any longitudinal study, the more incomplete the follow up, the lower will be the rate of adverse sensorineural outcome. [ABSTRACT FROM AUTHOR]

Introduction: There is debate about the type and intensity of early childhood intervention that is most helpful for children with developmental problems. The aim of the study was to determine whether a home-based programme provided over 12 months resulted in sustained improvement in development and behaviour 12 months after the intervention ceased. The characteristics of the children and families who benefited most from the intervention were also studied., Method: Randomized controlled trial. Participants A total of 59 children, aged 3-5 years, attending two early childhood intervention centres in Melbourne, Australia. Intervention Half of the subjects received an additional home-based programme consisting of 40 weekly visits., Main Outcome Measures: Bayley Scales of Infant Development and Wechsler Preschool and Primary Scale of Intelligence Revised, Preschool Behaviour Checklist, Bayley Behaviour Rating Scale and Behaviour Screening Questionnaire. All tests administered pre-intervention, following the intervention and 12 months later. Secondary outcome measures Family stress, support and empowerment., Results: Fifty-four children completed the assessments 12 months after conclusion of the intervention. Compared with the control group, improvement in aspects of cognitive development in the children who received the extra intervention was sustained 1 year later (P= 0.007) while significant behavioural differences post intervention were not. Analyses of the data by the Reliable Change Index indicated improvement of clinical significance occurred in non-verbal areas. In contrast to the control group who deteriorated, language skills in the intervention group remained stable. Improvements were significantly associated with higher stress in the families., Conclusion: Improvements following the provision of a home-based programme to preschool children with developmental disabilities were sustained 1 year later. Children from highly stressed families appeared to benefit most, reinforcing the importance of involving families in early childhood intervention programmes.

Objective: This study aimed to (1) investigate whether provision of a home-based program in addition to a center-based program improves development in young children with disabilities and coping abilities of their families and (2) describe the characteristics of children and families who benefit most from the intervention., Methods: Fifty-nine children, aged 3-5 years, with no cerebral palsy, participated in the study. Half of the group was randomized to receive an additional program in their homes. A special education teacher provided 40 visits over 12 months working with the families to help generalize skills to the home environment and assist with their concerns. All children were assessed before and after the intervention, and families completed questionnaires assessing family stress, support, and empowerment on both occasions. Differences in change over time and between the intervention and control group were analyzed by repeated measures and the association between characteristics of children and families with improved outcome by multivariate analysis of variance., Results: Change in cognitive development and behavior (in the centers) over time favored the children who received the extra intervention (p = .007 and p = .007, respectively). The groups did not differ on any of the family measures of change. Multivariate analysis of variance revealed more improvement for children in the intervention group from higher than lower stressed families., Conclusions: Results suggest the need for daily reinforcement of skills learned at the center-based program and the importance of involving families, especially those with few resources and relatively high stress.

A controlled longitudinal prospective study is reported of physical and neuropsychological progress up to 12 years in 152 children with congenital hypothyroidism (CH), detected by newborn screening in the Australian state of Victoria and born between the onset of screening in mid-1977 and December 1988. Linear growth of the CH children was normal. Throughout they were slightly heavier and the median head circumference was slightly larger compared with reference data. Those with thyroid aplasia required a marginally larger dose of thyroxine to achieve euthyroidism. Assessment of cognitive outcome in the children with permanent primary CH revealed the mean scores at 2, 5 and 8 years to be from 8.5 (p<0.001) to 10.2 (p<0.001) points lower than in a group of 60 euthyroid controls. However, there was large overlap and, of the affected children, only 10.1% at 2 years, 3.9% at 5 years and 6.8% at 8 years fell more than 2 SD below the means of the euthyroid controls. On univariate analysis, variables shown to have significant correlation with cognitive outcome at 8 years in the CH children were newborn activity, baseline TT4 and FTI, initial T4 dosage, socio-economic classification, maternal age, maternal education and presence of a serious accompanying disorder. On multiple regression analysis, significant variables were baseline bone age, maternal age and education, and presence of a serious accompanying disorder. No single thyroidal or extra-thyroidal variable could be identified to account for the discrepancy between the children with CH and the controls.

Clinical, demographic and laboratory data from infants with congenital hypothyroidism (CH) born in the Australian state of Victoria from the commencement of neonatal screening in mid-1977 until December 1988 are reported. These provide a baseline for a 12-year prospective longitudinal study on physical and neuro-psychological outcome until mid-1997, the subject of a second paper. Infants with CH were detected using a primary TT4 screening test. Demographic data were collected prospectively using a clinical assessment protocol. Nearly all affected infants underwent 99mTc pertechnetate scanning at the initial assessment to determine the underlying aetiology of their hypothyroidism. 704,723 infants were screened and 199 with permanent primary hypothyroidism (one in 3,541) were identified. The most common aetiologies were thyroid ectopia (46%), thyroid aplasia (33%), and 'dyshormonogenesis' (11%). The clinical abnormalities classically described in CH were more evident in infants with aplasia, and the striking female preponderance in infants with thyroid dysplasia (syn. dysgenesis) was confirmed. Other features included increased frequencies of 'dyshormonogenesis' in infants of parents of Middle-Eastern origin and of labour induction in infants with dysplasia. A closed posterior fontanelle was not found in any infant with thyroid aplasia.

The aim of this study was to compare cognition, academic progress, behavior, and self-concept children of very low birth weight (VLBW, birth weight < 1501 g) born in the period 1980 to 1982 with randomly selected children of normal birth weight (NBW, birth weight > 2,499 g). At 14 years of age, 130 (84.4%) of 154 VLBW and 42 (70.0%) of 60 NBW children were assessed. Ten VLBW children and one NBW child who had cerebral palsy were excluded. VLBW children scored at a significantly lower level on all three composite scales of the Wechsler Intelligence Scale for Children, 3rd Edition. VLBW children were also significantly disadvantaged on more specific cognitive processes, including tests of visual processing and visual memory and on subtests reflecting learning and problem solving. Only in arithmetic was a difference between the groups discerned on tests of achievement. Significantly more VLBW children were rated by teachers as socially rejected and by their parents as having learning problems at school. VLBW children had significantly reduced self-esteem. VLBW children had more cognitive, academic, and behavioral problems and lower self-esteem at 14 years of age than NBW control subjects.

Objective: To determine whether exposure to antenatal corticosteroid therapy was associated with adverse effects on growth, sensorineural outcome, or lung function of children of birth weight <1501 g at 14 years of age., Design: Cohort study., Setting: The Royal Women's Hospital, Melbourne, Australia., Subjects: One hundred fifty-four consecutive survivors born from October 1, 1980 to March 31, 1982., Interventions: The mothers of 78 survivors (51%) had been given corticosteroids antenatally to accelerate fetal lung maturation. Treatment with antenatal corticosteroids was nonrandom. No mother received >1 course of corticosteroids., Outcome Measures: The children were assessed at 14 years of age, corrected for prematurity. All assessors were unaware of the exposure of the child to antenatal corticosteroids. The assessments included measurements of growth and neurological, cognitive, and lung function. Growth measurements were converted into z scores (standard deviation) for the appropriate age and gender., Results: Of the 154 survivors, 130 (84%) were assessed at 14 years of age. Overall, the children exposed to antenatal corticosteroids were significantly taller (height z score; mean difference:.39; 95% confidence interval:.001-. 79) and had better cognitive functioning (Wechsler Intelligence Scale for Children-Third Edition Full Scale; IQ mean difference: 6. 2; 95% confidence interval:.8-11.6) than those not exposed to corticosteroids. There were no other differences in sensorineural outcomes between the groups. Lung function was not significantly different between the groups. No conclusions were altered by adjustment for confounding variables., Conclusions: Exposure to 1 course of antenatal corticosteroid therapy was associated with some clinically and statistically improved outcomes at 14 years of age in children of birth weight <1501 g, with no obvious adverse effects on growth or on sensorineural, cognitive, or lung function. corticosteroids, growth, cognitive, IQ, lung function, adolescence.

The aims of this study were to determine the outcome to 5 years of age for fetuses 24-26 weeks of gestational age from the obstetric viewpoint, and to determine if their outcome has improved over time. Consecutive fetuses with gestational ages from 24-26 weeks born at the Royal Women's Hospital, Melbourne, during 2 separate eras, Era 1 (1977-1982; n = 198) and Era 2 (1985-1987; n = 128) were studied and their outcome to 5 years of age determined. Fetuses referred with lethal malformations or clearly dead before the onset of labour were excluded. The stillbirth rates were similar in both eras (Era 1 23.7%, Era 2 21.9%), but the proportion of survivors to 5 years of age was much higher in Era 2 (Era 1 19.7%, Era 2 30.5%, X2 = 5.0, p < 0.03; odds ratio 1.80; 95% confidence interval [CI] 1.07 to 3.04). Overall, both the proportion and the absolute number of severely disabled children fell over time; 4 children survived with severe sensorineural disability in the 5 1/4 years of Era 1, but only one child in the 3 years of Era 2. From the obstetric viewpoint, only 1.5% of total births survived with a severe sensorineural disability, no higher than the rate expected for children born at term. Fetuses born at 24-26 weeks of gestational age need not contribute disproportionately to the number of severely disabled children in the community; furthermore, their outcome is improving over time. From the obstetrician's viewpoint, survival chances rather than sensorineural outcome should dominate decision-making at these extremely preterm gestations.

A brief description was presented of the evolution of workplace exposure monitoring. Measurements began in the 1930s and developed through particle counting to the introduction of the membrane filter, light microscope method in the mid-1960s. It is important to be aware that most data from the past were collected in relation to workplace control. The membrane filter phase contrast microscope method provides an index of exposure. Fibres with diameters less than 0.2 microns are unlikely to be counted. The method is not capable of analysing individual fibre types and consequently all fibres are counted. There have been several changes to the detail of the membrane filter method. The possible effect of these changes were presented. The Asbestos International Association (AIA) has implemented a fibre counting performance trial and also an annual return of workplace monitoring data. A WHO project is in progress with the objective of harmonizing the membrane filter method for fibre counting of all fibre types using phase contrast microscopy.

Cognition, school performance, and behavior were assessed at 8 years of age in 132 very low birth weight (VLBW) children free of major sensorineural impairments, and the results were contrasted with a randomly selected control group of normal birth weight (NBW) children. Considering their fragile beginnings, the majority of VLBW children were developing normally and were reading and performing in most academic and social areas as well as the NBW children. However, VLBW children were significantly inferior to NBW children on tests of cognition, including tests of intelligence and visual memory, and on teacher's reports of motor skills and initiative. In addition, proportionally more VLBW children (20.5%) than NBW children (5.9%) were reported by their parents to be not coping at school.

Objective: To determine the sensorineural outcome at 2 years of age in a complete cohort of survivors of fetal intravascular transfusions., Methods: From March 1984 to May 1990, 38 of 52 consecutive fetuses (73%) suffering from severe erythroblastosis survived attempted intravascular transfusions at the Royal Women's Hospital, Melbourne. At 2 years of age, corrected for prematurity where appropriate, the survivors had a psychological assessment, including the mental developmental index of the Bayley scales, and a standardized neurodevelopmental examination., Results: Only one transfused child had a severe sensorineural disability, with severe developmental delay and multiple minor motor seizures. Another child was moderately disabled with spastic hemiplegia. In neither case were complications of an intravascular transfusion the likely explanation for the disability. Only one other child had a mental developmental index in the suspect range. The remaining 35 children (92.1%) had no sensorineural disability. The overall rate of sensorineural impairments and disabilities was lower in the group transfused than in previous reports of survivors of intraperitoneal transfusions. The mean mental developmental index was significantly higher in the transfused group than in a control group of normal birth weight children., Conclusion: Children who survive fetal intravascular transfusions compare favorably not only with other high-risk survivors, but also with low-risk children.

The aim of this study was to assess all relevant aspects of auditory function, including acuity and perception, of a cohort of extremely low birth weight (< 1000 g) children who survived to 8 years of age; 42 of the 59 consecutive survivors born over a 4-year period from January 1, 1977, had a full auditory assessment. Of the 42 children, 4 (9.5%) had a sensorineural hearing impairment, 5 (11.9%) had a conductive hearing impairment, 24 (57.1%) had figure/ground differentiation problems, and 20 (47.6%) had a short-term auditory memory problem. The 4 children with sensorineural hearing impairments had had significantly higher maximum concentrations of bilirubin in the newborn period (median 167 mumol/L vs 138 mumol/L and had required more intensive care; at 8 years of age they were significantly disadvantaged in verbal ability. The 5 children with conductive hearing impairments were not significantly different on any perinatal or other 8-year outcome variables. The proportion with figure/ground differentiation problems (57.1%) was significantly higher than in a normative population (11.7%, chi 2 = 24.2). Extremely low birth weight children with figure/ground differentiation problems were more likely to be restless in the classroom (45.0% [9/20]) than those without these problems (16.7% [2/12]), but the difference was not statistically significant (chi 2 = 2.7). Children with short-term auditory memory problems had significantly higher maximum bilirubin concentrations in the newborn period (median 152 mumol/L vs 137.5 mumol/L). At 8 years of age they had significantly reduced intelligence and reading ability.(ABSTRACT TRUNCATED AT 250 WORDS)

Objective: To determine whether improvement in the survival rate of infants with a birthweight of less than 1501 g was accompanied by an increase in the rate of neurological impairment or disability among the survivors., Design, Setting and Patients: Two cohorts of consecutive very low birthweight infants (birthweight less than 1501 g) in one tertiary perinatal centre were followed prospectively to eight years of age; for both cohorts, comparison groups of children of birthweight more than 1501 g were randomly selected from hospital births., Interventions: The first cohort was born before the introduction of assisted ventilation (1966-1970), the second after assisted ventilation was well established (1980-1982)., Main Outcome Measures: Comparisons between cohorts, at eight years of age, of the survival rates and the rates of severe sensorineural impairments and disabilities., Results: The survival rate for very low birthweight infants to eight years of age almost doubled between these cohorts, from 37.1% to 67.8% (odds ratio [OR], 3.4; 95% confidence interval [CI], 2.5-4.7; chi 2 = 57.6; P much less than 0.0001). The biggest gain was the increase in non-disabled survivors at eight years of age, from 52.6% in the first cohort to 80.8% in the second cohort (OR, 3.5; 95% CI, 2.2-5.7; chi 2 = 26.7; P less than 0.0001). Furthermore, the rate of severe disabilities in survivors fell substantially, from 13.6% to 4.1% (OR, 0.31; 95% CI, 0.14-0.69; chi 2 = 8.3; P less than 0.01). Of specific impairments, the rate of severe sensorineural deafness fell substantially (3.2% to 0%: OR, 0.14, 95% CI, 0.02-0.81; chi 2 = 4.8; P less than 0.05), as did the rate of severe intellectual impairment (13.0% to 2.7%: OR, 0.25; 95% CI, 0.11-0.57; chi 2 = 10.7; P less than 0.002). Only the rate of cerebral palsy increased, but not significantly (2.6% to 6.8%; OR, 2.6; 95% CI, 0.89-7.6; chi 2 = 3.0)., Conclusions: It has been possible to improve the survival rate of very low birthweight infants over time without increasing the number of severely disabled survivors. Whether the long-term outcome for these infants is continuing to improve with more recent advances in perinatal care remains to be determined.

The aim of this study was to assess the outcome up to 2 years of age for the fetus of birth weight 500-999 g, over time and in association with changes in obstetric care. Two consecutive cohorts of infants of birth weight 500-999 g were compared from two eras, 1977-1982 and 1985-1987, and their outcome up to 2 years of age was determined with particular emphasis on the effect of various obstetric interventions at the time of birth, such as cesarean delivery, electronic fetal monitoring, antenatal steroid therapy, and tocolytic therapy. The outcome to 2 years was analyzed by logistic function regression to adjust for imbalances in confounding perinatal variables. In the latter era, the survival rate to 2 years increased significantly by almost 50%, and only 7% of the survivors were severely disabled. The rates of delivery by cesarean and of electronic fetal monitoring both increased significantly in the latter era, but neither was associated with the improved outcome. The only variable associated with an improved outcome that was amenable to obstetric intervention at the time of birth was antenatal steroid therapy, which was used equally in both eras. The obstetrician may aid the fetus of birth weight 500-999 g by giving the mother steroids to accelerate fetal lung maturity, but cesarean cannot be recommended as the routine mode of delivery unless there are recognized maternal or fetal indications.

The occipitofrontal circumference was measured in all available children in the following cohorts at ages 2, 5, and 8 years: group 1, consisting of 79 children with birth weight between 500 and 999 g; group 2, with 111 children with birth weight between 1000 and 1499 g; and group 3 with 56 children with birth weight greater than 2500 g; all were white with no signs of moderate or severe cerebral palsy. National Center for Health Statistics reference values indicated substantially more children with an occipitofrontal circumference lower than the 10th percentile, particularly at age 2 years, compared with Nellhaus reference data. Occipitofrontal circumference was the head measurement best correlated with the Full Scale IQ on the Wechsler Intelligence Scale for Children-Revised. Dolichocephaly, often seen in very-low-birth-weight children was unrelated to IQ, and correction of occipitofrontal circumference for dolichocephaly was rarely of clinical importance.

Of 149 infants liveborn in a large maternity hospital in 1980 to 1982 and delivered between 24 and 29 completed weeks of gestation inclusive, 91 (61%) survived; 88 (97%) survivors were assessed at 8 years' corrected age; 77% of children were not disabled; disability was mild in 13%, moderate in 2% and severe in 4% of children. Although survival decreased with decreasing gestation, disability in survivors did not increase. An earlier assessment of the same children at approximately 2 years of age had been unduly pessimistic particularly for those born less than or equal to 26 weeks' gestation. The only other reports in the literature on outcome by gestation have all assessed the children in early childhood, and estimates of severe disability rates from these studies will probably also be too pessimistic. Since the rate of severe disabilities in infants of borderline viability is not much higher than in more mature infants the obstetrician should mainly consider survival chances for the fetus, and not be overly concerned with long-term neurological outcome, when making clinical decisions.

Survival and neurodevelopmental outcome to 2 years were determined for two cohorts of infants weighing 500 to 999 gm at birth, born in a tertiary maternity hospital. Live births increased over time from an annual average of 48.7 in the first era (January 1977 to March 1982) to 64.6 in the second era (January 1985 to December 1987), largely from referrals of additional mothers with pregnancy complications. In the first era, 33.6% (86/256) of infants survived to 2 years; the survival rate improved significantly to 45.9% (89/194) in era 2. After adjustment for birth weight, the odds ratio for survival in era 2 versus era 1 was 1.39 (95% confidence interval = 1.12, 1.73; p less than 0.01). One known survivor in each era was not seen at 2 years of age. In the first era, 59.3% (51/86) of 2-year-old children were free of disability compared with 68.5% (61/89) in era 2 (NS), but the Mental Development Index of the Bayley Scales improved significantly, from 90.0 in era 1 to 98.0 in era 2. For infants weighing less than 800 gm at birth, not only did the 2-year survival rate improve, adjusted for birth weight (odds ratio = 1.53; 95% confidence interval = 1.06, 2.20; p less than 0.05), but there was also a significant reduction in neurologic disabilities in survivors (p = 0.03). For infants weighing 800 to 999 gm at birth, there was a significant improvement in the survival rate, adjusted for birth weight (odds ratio = 1.37; 95% confidence interval = 1.04, 1.79; p less than 0.05), but the rate of neurologic disabilities was unchanged. Increased survival in our tertiary maternity center was achieved without increasing the annual number of severely disabled 2-year-old survivors.

The study involved a cohort of 59 consecutive survivors with birthweights less than 1000 g, born between 1977 and 1980, to 8 years of age. The aim of the report was to determine if those survivors who had received more oxygen and ventilator therapy differed in their outcome compared with those who had received less oxygen and ventilation. Children were graded into four groups, characterized by decreasing durations of oxygen and ventilation. Children who had received less oxygen and ventilation were more likely to be below the third percentile for weight at 2, 5 and 8 years but the trends were significant only at 2 and 5 years (P = 0.006, P = 0.013 and P = 0.19 respectively). The rate of cerebral palsy was 8% at 8 years; the only children with severe or moderate disabilities from their cerebral palsy were in the lowest oxygen and ventilation group (n = 4, P less than 0.02). The frequency of hospital re-admission and the duration of re-hospitalization did not vary significantly between the four groups at any age. The rates of recurrent wheezing episodes or asthma did not vary significantly between the groups. Although the cohort as a whole had some impairment of lung function compared with healthy full-term controls, there was no significant difference between the four groups. Contrary to expectations, our findings suggest lower rates of poor growth and adverse neurological outcomes with increasing durations of oxygen and ventilation in the newborn period.

The stability of the diagnosis of cerebral palsy from 2 to 5 years of age was examined in 83 children of birthweight under 1000 gm, and 112 of birthweight 1000 to 1500 gm. In 20 2-year-old children with cerebral palsy, the diagnosis persisted in 11 (55%, 95% confidence intervals 35.1 to 76.9%); 2 of 175 children (1.1%) free of cerebral palsy at 2 years of age subsequently developed the condition. Severe or moderate cerebral palsy at 2 years persisted in all eight children (100%). In 9 of 12 children in whom cerebral palsy at 2 years had disappeared by 5 years, minor neurologic abnormalities and left-hand preference occurred frequently but mean psychologic tests scores were similar to children always free of cerebral palsy. In this cohort, cerebral palsy at 2 years was not a static condition, but overestimated later prevalence.

Rehospitalizations and ongoing health problems at 5 years of age were contrasted between 197 very-low-birth-weight (VLBW) children and 47 normal-birth-weight children. At 5 years of age, the VLBW children had a mean of 1.7 hospital admissions and 8.5 days in a hospital; these means were significantly more than the 0.5 admissions and 1.7 days, respectively, for the normal-birth-weight children. Overall, respiratory tract problems and ear, nose, and throat surgery were the most common reasons for readmissions. Malformations and intensive care sequelae infrequently caused readmissions. No combination of sociodemographic or perinatal variables identified the VLBW children who were destined for hospital readmissions. At 5 years of age, the VLBW children, compared with the normal-birth-weight children, had significantly more ongoing sensorineural problems (29.9% and 10.6%, respectively), ongoing respiratory problems (39.6% and 19.1%, respectively), and other morbidities (31.0% and 17.0%, respectively). The VLBW children, compared with the normal-birth-weight children, had more hospital admissions during the first 5 years of life and more ongoing problems at 5 years of age.

Of 154 consecutive survivors of birthweight 500 to 1500 gm, 139 (90.3%) were seen at 5 years of age, corrected for prematurity, and 137 (89%) were able to be fully assessed by both the psychologist and pediatrician. All but two children had had serial cranial ultrasonography with a linear array real-time scanner in the neonatal period. At 5 years, of 39 children with cerebral ultrasound abnormalities detected during their primary hospitalization, seven (17.9%) had cerebral palsy, but 32 (82.1%) did not. A further three children with cerebral palsy at 5 years had had no cerebral abnormalities on ultrasound. Of the cerebral abnormalities diagnosed by ultrasound, ventricular dilation, with or without cerebroventricular hemorrhage, had the highest positive predictive value (40%) for cerebral palsy at 5 years. In the 127 children free from cerebral palsy at 5 years, two (1.6%) had severe intellectual impairment, both of whom had had normal cerebral ultrasonography. Although neonatal cranial ultrasonography with a linear array was somewhat predictive of cerebral palsy at 5 years, the majority of infants with abnormal scans had no severe sensorineural impairments at 5 years.

When using tests of infant development and intelligence in children born prematurely, the subject's age is commonly corrected for the degree of prematurity. However, there is disagreement: first, on whether this correction should ever be applied, and second, at what age to discontinue the adjustment. In a theoretical model, the difference between corrected and uncorrected scores in early infancy was massive and the difference remained clinically important until the age of 8.5 years in children who were born extremely prematurely. The clinical implications of using corrected or uncorrected scores were then evaluated in 174 very low birthweight children without severe sensorineural disabilities and with paired Bayley Mental Development Index (MDI) and Wechsler Preschool and Primary Scales of Intelligence (WPPSI) full scale scores. Failure to correct for prematurity reduced the mean MDI by 12.1 points but reduced the mean WPPSI by only 4.1 points. The disparity between individual MDI and WPPSI scores increased significantly with decreasing gestational age if uncorrected scores were used (P = 0.015) but not if scores were corrected. Using corrected scores, the MDI correctly predicted the WPPSI category in 86.1% of children (P less than 0.001) but in only 54.6% using uncorrected scores (the difference was not significant). It is suggested that a practical solution to the dilemma is to correct test scores for prematurity in the age range 2-8.5 years recognizing that only in extremely immature infants will uncorrected scores be substantially lower than corrected ones at a later age.

Of 55 consecutive long-term survivors of birth weight 500 to 999 g, complete psychologic and pediatric data were available for 54 children at 2 years corrected age and for 50 at age at least 5 1/2 years. At the latter age, 60% (30 of 50) were not impaired, 10% (five of 50) had severe sensorineural or intellectual impairments, 10% (five of 50) had mild to moderately impairment, and 20% (10 of 50) had minor neurobehavioural abnormalities. Sensorineural deafness in one child and bilateral blindness in one remained stable over time, but of six children with spastic cerebral palsy at 2 years, only three retained this diagnosis at 5 1/2 years. The mean Mental Developmental Index (MDI) on the Bayley Scales at 2 years was 91.1, significantly below the test mean; by 5 1/2 years the mean full scale of the Wechsler Preschool and Primary Scales of Intelligence (WPPSI) was 101.8. The MDI correlated highly with the full-scale WPPSI (r = 0.7), but for individual children it was not always an accurate predictor of 5-year ability. Between 2 and 5 1/2 years there was a substantial reordering within four categories of impairment: findings in 27 children were improved, four were judged to become more severely impaired over time, and 19 did not change. We conclude that our 2-year assessment often underrated the potential of the children as expressed at 5 1/2 years, and that 2 years is too early for reliable classification of children of birth weight 500 to 999 g.

A cohort of 678 consecutive very low birth weight infants, liveborn in one tertiary institution during a 63-month period, was studied to investigate whether antenatal steroid therapy had any beneficial or harmful effects on mortality or morbidity over the first 2 years of life. Comparing the 244 babies who received treatment with the 434 controls, 195 (79.9%) and 265 (61.1%), respectively, were discharged home (P less than 0.001). Mortality in the treated group remained substantially lower and was almost halved after adjustment for birth weight, extreme immaturity, lethal malformations, and confounding obstetric variables (P = 0.001). Fatal cases of respiratory distress syndrome were less common in the treated group (P = 0.044). Of in-hospital survivors, those in the treated group required less positive pressure respiratory support (P = 0.003) and fewer days in oxygen (P = 0.018), and the incidences of bronchopulmonary dysplasia (P = 0.003) and patent ductus arteriosus (P = 0.002) were lower. Two-year survivors who had received treatment were heavier (P = 0.016) and had larger head circumferences (P = 0.029). These beneficial associations in the treated group were not at the expense of increased rates of infection or adverse neurologic outcome. We did not detect any adverse effects of antenatal steroid therapy on any relevant aspect of mortality or morbidity in infancy under circumstances in which the chances of finding substantial differences were high.

Between January 1, 1977 and March 31, 1982, 84 of 131 (64.1%) consecutive liveborn very low birth-weight (VLBW) singletons delivered after breech presentation were discharged home alive. Of babies delivered by Caesarean section 40 of 47 (85.1%) survived, versus 44 of 84 (52.4%) delivered vaginally (X2 = 12.6, p less than 0.0005). When differences in birthweight and antenatal steroid therapy were adjusted by multiple regression analysis, after excluding a lethally malformed baby who was diagnosed antenatally and babies who were not treated aggressively because they were thought to be too immature (n = 19), those delivered by Caesarean section were still more likely to survive (p = 0.038). In survivors completely assessed at 2 years of corrected age, there was a statistically significant association between Caesarean section and reduced handicap (p = 0.019). For the VLBW singleton breech, there is good evidence that delivery by Caesarean section is beneficial.

In 1966-70, the survival rate for very low-birthweight (VLBW) children born in a tertiary perinatal centre was 37.1 per cent but by 1980-82 it had increased to 68.3 per cent. The latter cohort had a significantly reduced prevalence of strabismus, myopia and a head circumference under the 10th percentile, but a significantly increased prevalence of cerebral palsy compared with the 1966-70 VLBW children. Survivors born in 1980-82 had a significantly increased mean Mental Development Index (MDI) on the Bayley Scales compared with the sub-group of survivors born in 1968-70 but there was also a significant improvement in mean MDI over time for a group of normal-birthweight children. No improvement of MDI scores of VLBW survivors in the 1980-82 cohort could be attributed solely to perinatal care. The two-year-old VLBW children in the 1980-82 cohort had similar rates of sensorineural impairments, disabilities and mean MDI to those who would have survived with the care available in 1966-70. It is concluded that survival of VLBW infants has improved in recent times but that neurodevelopmental outcome still lags behind that of normal-birthweight peers.

The survival rate of infants born alive between 24 and 28 weeks of gestation has increased significantly in this tertiary care centre, from about 9% in the first cohort studied (1966-1970), to 19.5% in the second cohort (1971-1974) and 50.3% in the third cohort (1977-1982); the borderline of practical viability decreased from 27 to 24 weeks over the years of the study. The number of mothers with a history of prior termination of pregnancy increased about sixfold from the second to the third cohorts but the rate of premature births increased by only 50%. The augmented survival rate was accompanied by an increase in the prevalence and total number of children with cerebral palsy, but bilateral blindness due to retinopathy of prematurity and severe sensorineural deafness were reduced. When 96% of children in the third cohort were assessed at two years of age. 13% had severe handicaps, 59% were considered normal and in 24% some handicap was suspected. The serious handicap rate was 28% for children born at 24-26 weeks compared with 8.5% for those born at 27-28 weeks of gestation.

Over a 63-month period beginning January 1, 1977, 258 infants with birth weights of 500-999 g were born alive at one tertiary perinatal center; 170 were offered full intensive care. The mothers of 67 (39.4%) of these 170 infants had been given betamethasone antenatally to accelerate fetal lung maturation. Of the 67 infants exposed to steroids antenatally, 46 (68.7%) survived their primary hospitalization, compared with 43 (41.7%) of the 103 infants who had not been exposed to steroids. This difference is highly significant (chi 2 = 10.7; P less than .005) but is biased because infants in the steroid group had a better prognosis. After adjustment for discrepancies in birth weight and gestational age and other confounding obstetric variables, survival in the steroid group remained substantially higher (relative odds of survival 1.85, 95% confidence intervals 1.16-2.86; P = .006). The improvements in survival were not at the expense of increased rates of chronic ill health or impairments of growth neurodevelopment up to at least 5 years of age. For extremely immature and extremely low birth weight infants, steroids are rarely contraindicated on fetal grounds.

Consecutive surviving children weighing less than 1501 g when born in 1966-70 were followed prospectively: 87% (146/168) attended normal secondary schools, 4% (7/168) attended schools for those with special needs and 9% (15/168) were untraced. The psychologist assessed 140 children at a mean age of 14.5 years. The mean WISC-R Verbal Score of 89.7 was almost identical to that achieved by the children at 8 years of age (89.2). Thirty three children (24%) had delay in Reading Accuracy on the Neale Analysis of Reading Ability, whilst 66 children (48%) were delayed on the Comprehension Scale. Social class and duration of maternal education were significant predictors of the WISC-R Verbal Scores and Reading Comprehension at 14.5 years but the total variance explained was small. The Bayley Development Index (MDI) available for half of the children at 2 years often underestimated their potential as defined by the WISC-R Verbal Score at 14.5 years. The 8 year intelligence (WISC-R) and reading measures (Neale) were significantly and highly associated with the corresponding measures at 14.5 years. It was concluded that 8 years was an appropriate age to evaluate the outcome of the children and to identify many of those needing educational intervention. The spasmodic nature and sometimes short duration of the help received by many of the children underlines the need for more appropriate intervention for children with learning difficulties.

Of 456 consecutive infants born in a tertiary maternity centre in 1966-70 and of birthweight under 1501 g, 171 (37.5%) survived their primary hospitalization. Subsequently three children died and the outcome of 142 (90.5%) of the remaining children presumably still alive were reviewed at a mean age of 14.5 years. Four children had cerebral palsy although only one child was legally blind, 31.6% (48/152) had an existing or corrected visual impairment; visual impairments occurred significantly more frequently in those of birthweight under 1251 g or those born before 29 weeks gestation. Six children required hearing aids and three others were still epileptic. Four children were chronic asthmatics and one had rheumatoid arthritis. None had disabling malformations and there was no delay in pubertal changes. The distributions of weight, height and head circumference percentiles were not significantly different from a standard Australian population. For children in the cohort, weights and heights were under the 10th percentile in 13.4% and 14.1%, respectively. Of the 30 children with birthweights under the 10th percentile and who were reviewed as teenagers, only eight (26.7%) were still in this weight category.

Fifty-nine infants of birthweight 500 to 999 g born in 1977 to 1980 and 132 infants of birthweight 1000 to 1500 g born in 1977 to 1978 were reviewed at two years corrected age. For the whole cohort, cerebral palsy was found in 12.6%, bilateral deafness in 1%, blindness in 1% and severe developmental delay in 12%. There was no significant difference in these disabilities between the groups of larger and smaller infants; 37.7% of the cohort was readmitted to hospital on at least one occasion, 35.6% of children had wheezing episodes and/or lower respiratory tract infections which together accounted for 51% of hospitalizations. The infants of birthweight 500 to 999 g tended to require more frequent and prolonged hospitalizations. Dolicocephalic head shape, chest deformities, iatrogenic sequelae from intensive care, poor growth and cicatricial retrolental fibroplasia were significantly more frequent in children of birthweight 500 to 999 g. Parents reported that 39% of their children had 'colic', 31.6% had sleep disturbance and 25% had multiple behavioural problems. Low frustration tolerance, inability to wait, hypo- or hyperactivity and an inappropriate relationship with the mother as measured by the psychologist all occurred significantly more frequently in children of birthweight of less than 1000 g. This report confirms the belief that a comprehensive follow-up is required for very low birthweight (VLBW) children because significant health problems continue after primary hospitalization.

One hundred and forty-eight (95.5%) of 155 consecutive two-year survivors of 227 very low birthweight (VLBW, less than 1501 g) infants and 50 (83.3%) of 60 infants of normal birthweight who were selected at random, all of whom were born at the Royal Women's Hospital, Melbourne from October 1980 to March 1982, were seen at the age of two years. Social, psychological and health data were compared between the groups. The mean Bayley Mental Developmental Index scores of VLBW children were significantly lower; the prevalence of major handicaps and poor growth (height and weight below the 10th percentile), and the number of hospital readmissions, wheezing episodes, major and minor congenital anomalies and postnatally-acquired malformations (for example, abnormally shaped skull) were significantly greater in VLBW children. There was a trend for a greater number of episodes of otitis media, lower respiratory tract infections and surgical procedures per child in VLBW children. Extremely low birthweight children (birthweight less than 1000 g) contributed significantly to this morbidity. Parents of VLBW children perceived significantly more problems with infant vomiting and behavioural disturbances at two years of age. The children of mothers of limited education, or immigrant status and non-fee paying or lower socioeconomic families had lower mean Bayley Mental Developmental Index scores but similar handicap rates and health status in both weight cohorts.

Of 60 consecutive survivors of birth weight 500-999 g, who were born in one tertiary perinatal centre from 1977 to 1980, 59 infants were assessed by a multidisciplinary team at two years of age (corrected for prematurity) and 58 children were evaluated when aged at least five years. At the latter examination, 9% of the 58 children who were assessed were severely disabled; 17% had a mild or moderate disability; and 74% had no important disability. For the 53 children who were tested, the means for the three scales of the Wechsler Preschool and Primary Scales of Intelligence were just above the test mean. The psychologist noted behavioural problems during her assessment in 50% of children, and 29% of mothers reported behavioural problems which could interfere with schooling. At the age of five years and over, five (9%) children had cerebral palsy and one child was deaf. Twenty-two (38%) children had a visual impairment, although only one child was blind; the detection of retinopathy of prematurity in the nursery was an important risk factor. Health problems with readmissions to hospital and suboptimal growth were present in many children at two years of age and frequently these problems persisted to five years of age. Although only four (7%) children were too disabled to attend a normal school, apprehension exists that many of the other children may later encounter educational difficulties. At the two-years' assessment, ascertainment of cerebral palsy had not been complete or entirely accurate and the Mental Developmental Index of the Bayley Scale tended to underestimate the later psychological performance.

A large cohort of consecutive live births with gestational ages assessed antenatally from 24 to 28 weeks from one tertiary center was studied to determine the association between mode of delivery and in-hospital mortality and morbidity and morbidity at two years of age. Between 1 January 1977 and 31 March 1982, 52.8% (172 of 326) of such infants survived their primary hospitalization. Obstetric factors independently associated with improved survival were increasing gestational age (P less than .0001), the absence of maternal hypertension (P = .007), singleton pregnancy (P = .007), and antenatal steroid therapy (P = .018). Although 62.7% (32 of 51) of infants delivered by cesarean section survived compared with 50.9% (140 of 275) of infants delivered vaginally, the increased survival was not statistically significant (X 2 = 1.97). Moreover, the trend favoring cesarean section disappeared after adjustment for confounding obstetric factors. In univariate analyses cesarean births more frequently required ventilatory support and there was a trend toward a lower incidence of cerebroventricular hemorrhage; again, however, when adjusted for extraneous factors these associations disappeared. Of the 172 in-hospital survivors, five died at home unexpectedly; 162 of the remaining 167 were traced; 18 (11.1%) had cerebral palsy and two (1.2%) were deaf. Of the 111 children who were fully assessed, 13.5% had major handicaps, 23.4% were suspect, and 63.1% were free of handicap at two years' corrected age. There was no association between mode of delivery and frequency of handicap. Little evidence was found from mortality or morbidity data to support routine delivery of infants of borderline viability by cesarean section.

The rate of cerebral palsy and factors associated with its occurrence were determined in surviving 2-year-old very low birthweight (VLBW) infants born during an era of modern perinatal intensive care. Of the survivors, 12.5% (52/416) of those traced had spastic cerebral palsy. Motor handicaps were mild in 42%, moderate in 25%, and severe in 33% of children with cerebral palsy. The prevalence of cerebral palsy was similar in all birthweight groups up to the upper limit of 1500 gm, and was considerably higher than in survivors born in the same hospital a decade earlier. Although several perinatal variables were associated with the occurrence of cerebral palsy, either singly or in combination, little statistical or clinical confidence would be placed in these associations. Moreover, although 77% of children with cerebral palsy had one or more commonly recognized perinatal risk factors, almost identical rates of risk factors were present in normal children. The advent of cranial ultrasonography during the time of the study was associated with an increase in mortality but no effect on the prevalence of cerebral palsy. Cerebroventricular hemorrhage correlated poorly with the presence of cerebral palsy. The prevalence of cerebral palsy in surviving VLBW infants is unacceptably high; however, no obvious preventable factors in its etiology could be identified.

Cranial ultrasounds were performed on 218 (96%) of 227 liveborn infants of birthweight 500-1500 g delivered in the Royal Women's Hospital, Melbourne, Australia, in an 18-month period concluding in March 1982. Seventy-two (31.7%) of the children died; 28 children (38.9%) had cerebroventricular haemorrhage, 35 (48.6%) showed no bleeding and there were nine (12.5%) with no data. Paired necropsy and ultrasound data were congruent in 22 (88%) of 25 children. One hundred and forty-eight (95.5%) of 155 survivors were seen at 2 years of age. Forty-one (28%) had cerebroventricular haemorrhage; nine children (6%) had both ventricular dilatation and haemorrhage and two had ventricular dilatation alone. Apart from a marginal advance in gestation and higher number of immigrant and less educated mothers in children without cerebroventricular haemorrhage, all other perinatal, biographical and social variables between those with haemorrhage and those without were similar. The major handicap rate overall was 14.2% (21 patients). The children with cerebroventricular haemorrhage had a trend for greater prevalence of handicap and lower mean Bayley psychological scores. This was even more evident with ventricular dilatation being present. Of children with major handicap 57.1% (12/21) had normal serial ultrasound findings during their primary hospitalization. Major handicap occurred in 15% (3/20) of children with grade 1 haemorrhage, 23.5% (4/17) with grade 2 or 3 bleeds and 25% (1/4) of those with grade 4 haemorrhage. Laterality of cerebral palsy did not correlate with ultrasound findings. Ultrasound findings did not improve statistical prediction of deaths or major handicap.

The cognitive development at 2 and 5 years of a cohort of extremely low birthweight (ELBW) children (birthweight 500-999 g) was compared with that of cohorts of larger very low birthweight (VLBW) children (birthweight 1000-1500 g) and normal birthweight (NBW) children (birthweight greater than 2500 g) to determine whether the improvements in cognitive function of ELBW infants between 2 and 5 years are apparent or real. At 2 years of age, ELBW children had a mean Mental Developmental Index (MDI) on the Bayley Scales of 90.4, significantly lower than the means of 100.3 for the larger VLBW children (P = 0.006), and 107.8 for the NBW children (P = 0.0002). However by 5 years the mean scores on the Wechsler Preschool and Primary Scales of Intelligence (WPPSI) full-scale for the ELBW and larger VLBW children were virtually identical (105.9 and 106.0 respectively)--but still lower than the mean WPPSI full-scale of 114.6 for the NBW children. After standardizing the MDI and WPPSI scores relative to the NBW children, the ELBW children improved between 2 and 5 years (paired t-test, t = 3.2, P = 0.004) whereas the larger VLBW infants did not. We postulate that ELBW children require more time than larger VLBW children after birth to compensate for perinatal and other stresses, and that developmental delay at 2 years may not always persist to 5 years.