Showing posts with label development. Show all posts
Showing posts with label development. Show all posts

Wednesday, July 8, 2015

Does Screening for Speech and Language Delay in Children Less Than 5 Years of Age Make a Difference? A New Study Speaks Up and Says We Don’t Know

By: Lewis First, MD, MS; Editor-in-Chief 
 
          Although many of us likely do some form of screening for speech and language delay in our young patients under 5 years of age, believe it or not, no formal recommendations exists as of now for us to do that in terms of making a difference in improving a child’s development in this important area.  
      It is for that reason that Wallace et al. (doi: 10.1542/peds.2014-3889) performed an updated systematic review following up on one done almost a decade ago by the United States Preventive Services Task Force.  Interestingly enough, despite finding 23 studies evaluating the accuracy of screening tools, sensitivity ranged from 50 to 94% and specificity from 45 to 96% and only a few reported improved outcomes in limited areas of speech and language.  While more detailed evaluations can identify speech and language areas, the question is whether primary care providers can use a valid and reliable screening tool that would prompt the appropriate referral.
      Based on this review, available screening tools need work, and only a few treatments may be effective.  So should we stop screening for speech and language disorders and simply refer children for full evaluations if parents request that?  Behavioral and developmental specialists Drs. Robert Voight and Pasquale Accardo help us make sense of this review in an accompanying commentary (doi: 10.1542/peds.2015-0211) that must be read in partnership with this article. 
     Doing so will help you decide how best to evaluate speech and language issues in your office.  Do you agree with the conclusions of the review?  Are there screening tools or treatment programs you have found helpful?  Share them with us by responding to this blog, sending us an e-letter or posting your thoughts on our Facebook or Twitter sites.

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Wednesday, June 17, 2015

The Role of Anesthesia in Infancy and Diminished Language and Cognition Abilities

By: Lewis First, MD, MS; Editor-in-Chief 

      In 2011 Pediatrics published its first study (10.1542/peds.2011-0351) and commentary (10.1542/peds.2011-2489) on the possible cognitive impairment seen in infants who had received general anesthesia. Since then there have been a number of studies in various journals, none of them definitive, but all suggestive of the possible association between general anesthesia given in infancy and possible changes in cognitive and behavioral outcomes in these children who received anesthesia when young. This week we share a study that further determines more specifically just what developmental effects general anesthesia may be associated with. 
      Backeljauw et al. (10.1542/peds.2014-3526) compare a group of children who had undergone surgery with general anesthesia before four years of age with those who had not and explore the results of neurocognitive testing when these children are between 5 and 18 years of age.  The results reveal an association with long-term decreases in language abilities and cognition in association with volumetric alterations in brain structure compared to controls.  Before jumping to causation, there are limitations to this study as pointed out by the authors—and certainly aspects of the surgery itself might be behind this rather than receiving general anesthesia, not to mention a variety of other confounders you are already probably thinking about. 
     Yet this study adds to the mounting concerns that make us want to know even more about whether there are factors with type of anesthesia, agent, dose, duration, etc. that may be playing a role in contributing to the cognitive issues being raised in this and other studies.  What is your take on studies like this?  Are parents asking you about the benefits and risks of general anesthesia for their infants? 
      Are you waiting on scheduling elective surgical procedures until your patients are older and the brain is more developed rather than developing?  We welcome your thoughts and comments by responding to this blog, posting an e-letter or simply sharing your comments with a post on our Facebook or Twitter sites.

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Thursday, May 28, 2015

When in Doubt, Go Outside and Play

By: Terrill Bravender  MD, MH, Editorial Board Member

      Children are surrounded by entertainment so much that we adults have almost completely changed our children’s environmental sensory exposures. Screens of all sorts are the most prominent and notorious addition to the lives of kids, but the idea that children need organized activities such as soccer practice, ballet lessons, or this lesson or that enrichment class has dramatically changed the way children are able to (or not able to) entertain themselves and explore their own passions. Children of all ages need opportunities to be creative, to explore their environments, and to develop their imagination. In other words: to play. The younger the child, the more critical these opportunities are, after all, preschool children learn best through imaginative play and too much interference will just get in the way. Because our indoor environments are filled with electronic entertainment; where will children get these free play opportunities? The answer is as simple as previous generations telling their children to “go outside”. Many child advocacy groups, from Free Range Children to those concerned about “nature deficit disorder” are trying to promote outdoor activities for kids.
      The National Association for Sport and Physical Education recommends that each day preschoolers in daycare get sixty minutes of free-play time, sixty minutes of teacher-led structured physical activities time, and some opportunity to go outdoors. In the current issue of Pediatrics, Tandon et al. (doi: 10.1542/peds.2014-2750) from Seattle Children’s Hospital describe the indoor and outdoor free-play opportunities among preschoolers enrolled in various daycare settings. Their findings are disheartening, even if they are unsurprising. Children were physically active for fifty-five minutes per day, with an average of thirty-two minutes outdoors. Based on the activity monitors the children were wearing, children were more physically active when participating in unstructured free-play outdoors than when they were indoors or were participating in teacher-led activities. The children were also expected to lie quietly in “naptime” for an average of almost two hours, or more than ¼ of their time in daycare. 
     High quality daycare should be structured to the needs of the children for whom they care. Older children, adolescents, and adults, spend inordinate amounts of time sitting down indoors. The least we can do for our preschoolers is to give them the opportunity for free play, preferably outdoors. Ideally, this would comprise the majority of their day doing what children should do: running around outdoors battling dragons, finding fairy houses, and saving the universe, all without a screen in sight.

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Monday, April 27, 2015

Neurodevelopmental Outcomes in Infants Who Experienced Cardiac Surgery: Are We Doing Better?

By: Lewis First, MD, MS; Editor-in-Chief    

          There have been a number of studies that have focused on neurodevelopmental differences in children who as infants undergo cardiac surgery for their congenital heart lesion.  Etiologies for these differences may range from simply hypoxia to the brain to the use of anesthetic agents—but given the decades of ongoing improvement in our surgical techniques—are we seeing better and better outcomes neurodevelopmentally as well?  Gaynor et al. (doi:10.1542/peds.2014-3825) get to the heart of the matter in an interesting study being released this week.  The authors reviewed all studies of developmental outcome in infants undergoing cardiac surgery from 1996 through 2009 to determine risk factors for poorer developmental outcomes.   
     Once one adjusts for these innate risk factors, one begins to see developmental improvement over time—but there is much more to learn from this study and to think about—since developmental abnormalities continue to be seen in this surgical population of patients. Dr. Leonard Rappaport, a behavioral and developmental pediatrician who published some of the earliest studies on developmental outcomes in infants undergoing cardiac surgery shares his perspective on how far we have come and yet how far we still need to go in an accompanying commentary (doi: 10.1542/peds.2015-0719) well worth reading along with this heartfelt summary of where we are developmentally over the past decade and a half of congenital cardiac surgical care.

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Monday, March 30, 2015

Follow-up Studies of Preterm and Late Preterm Infant Neurocognitive Performance Continue To Develop


By: Lewis First, MD, MS; Editor-in-Chief  
  
     Our readers tell us they learn a lot reading the studies we publish on long-term follow-up of infants born early particularly in terms of their neurodevelopment. Well this week we don’t want to disappoint our readers and therefore bring you three studies of interest in the area of cognitive development of preterm, and late preterm infants. 
      The first study by Burnett et al. (doi: 10.1542/peds.2014-3188) focuses on extremely preterm (less than 28 weeks) and extremely low birth weight (less than1000 g) infants in terms of their executive function, not just in infancy and toddlerhood but into adolescence. 
     Sadly, poor performance in executive function tasks seen early in life carries on into the teen years, and while some aspects of executive function improve over time, a number of aspects do not, suggesting the need to intervene sooner than later to try to further develop executive function skills over time.
      A second study by Heinonen et al. (doi: 10.1542/peds.2014-3556) looks at late preterm infants and follows their neurocognitive performance not just into adolescence, but into late adulthood. The authors traced a cohort of more than 900 men and women born in Finland in 1934-44 who were assessed  as adults with a battery of tests to identify signs of Alzheimer disease and believe it or not, those who were identified as late-preterm had a higher risk of showing neurocognitive impairment.  Interestingly enough however, those who were able to pursue higher education did not show such findings. 
     Finally there is a third study by Schonhaut et al. (doi:10.1542/peds.2014-1957)  that looks at developmental impairment relative to gestational age in moderate, late preterm and early term infants and once again, there is an inverse association between gestational age and developmental delay.
     There are a lot of interesting comments one can make about the findings in all three studies, and at the same time, one has to be amazed that cohorts of infants are now being followed not just into early childhood but through adolescence and into adulthood without major losses to follow-up.  As a result, we are learning more and more about the developmental outcomes associated with being born early.   
     To help make even more sense of these types of studies and what we can do to perhaps improve developmental outcomes in these patients, Dr. Betty Vohr (doi: 10.1542/peds.2015-0227) offers her perspective in a very interesting commentary.  Read all three studies and the commentary and then see what develops in regard to interventional strategies to improve developmental outcomes in these infants born preterm.

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Friday, March 6, 2015

Preterm and Late Preterm Infant Neurocognitive Performance Follow-up Studies Continue To Develop

By: Lewis First, MD, MS; Editor-in-Chief 

         Our readers tell us they learn a lot reading the studies we publish on long-term follow-up of infants born early particularly in terms of their neurodevelopment. Well this week we don’t want to disappoint, and therefore bring you three studies of interest in the area of cognitive development of preterm, and late preterm infants. The first study by Burnett et al.  (doi:10.1542/peds.2014-3556) focuses on extremely preterm (less than 28 weeks) and extremely low birth weight (less than 1000 g) infants in terms of their executive function, not just in infancy and toddlerhood but into adolescence. 
         Sadly, poor performance in executive function tasks seen early in life carries on into the teen years, and while some aspects of executive function improve over time, a number of aspects do not, suggesting the need to intervene sooner than later to try to further develop executive function skills over time.
         A second study by Heinonen et al. (doi:10.1542/peds.2014-3556) looks at late preterm infants and follows their neurocognitive performance not just into adolescence, but into late adulthood. The authors traced a cohort of more than 900 men and women born in Finland in 1934-44 who were assessed  as adults with a battery of tests to identify signs of Alzheimer disease and believe it or not, those who were identified as late-preterm had a higher risk of showing neurocognitive impairment.  Interestingly enough however, those who were able to pursue higher education did not show such findings. 
          Finally there is a third study by Schonhaut et al. (doi:10.1542/peds.2014-1957)  that looks at developmental impairment relative to gestational age in moderate, late preterm and early term infants and once again, there is an inverse association between gestational age and developmental delay.
          There are a lot of interesting comments one can make about the findings in all three studies, and at the same time, one has to be amazed that cohorts of infants are now being followed not just into early childhood but through adolescence and into adulthood without major losses to follow-up.  As a result, we are learning more and more about the developmental outcomes associated with being born early.  To help make even more sense of these types of studies and what we can do to perhaps improve developmental outcomes in these patients, Dr. Betty Vohr (doi:10.1542/peds.2015-0227) offers her perspective in a very interesting commentary.  Read all three studies and the commentary and then see what develops in regard to interventional strategies to improve developmental outcomes in these infants born preterm.

Related Links:

Monday, November 24, 2014

Postnatal Growth Following Prenatal Lead Exposure and Calcium Intake

By: Assistant Editor Lydia Furman, MD

Photo by F. Lamiot via Wikimedia Commons (edited)
Lead is a ubiquitous environmental toxin, with well appreciated deleterious effects on the neurodevelopment of young children. But what do we know about the physical growth of lead-exposed infants and children? Dr. Hong and colleagues prospectively examine the effect of maternal lead levels during early and late pregnancy on postnatal growth at birth and at 6, 12 and 24 months (doi: 10.1542./peds.2014-1658).

Lead does cross the placenta, so prenatal exposure clearly has potential to reach the developing fetus; however there is limited evidence to date of any impact on postnatal growth beyond the neonatal period (Schell et al, Am J Human Bio, 2009).

Certainly no lead level is considered “safe.” With a new focus on primary prevention, the CDC has established 5.0 micrograms/dL or greater as the lead level that identifies children who are in the highest 2.5 percent of US children based on the National Health and Nutrition Examination survey (NHANES) data on blood lead levels in children.

Previously the CDC used a “level of concern” of 10 micrograms/dL; however it became clear that even at these “low” levels there were negative effects on neurodevelopment as assessed at 24 months with the Bayley Scales of Infant Development (Tellez-Rojo et al, Pediatrics, 2006), on intelligence as assessed at age 6 years (Canfield et al, New England Journal of Medicine, 2003 and Jusko et al, Environmental Health Perspectives, 2007), and on reading readiness at kindergarten entry (McLaine et al, Pediatrics, 2013). With the new population-based 2.5 percentile level of 5.0 micrograms/dL, clinicians, public health departments and parents hope to have the opportunity to intervene earlier and prevent deleterious effects.

But with less than 5.0 micrograms/dL as a non-actionable level for children, any direct effect of prenatal lead levels higher than this on child growth would be surprising. Hong and colleagues studied a cohort of 1,150 pregnant women whose mean lead level of 1.25 micrograms/dL was actually much lower.  Their unexpected results are a call to action for public health servants, policy makers and child advocates.

The authors further asked whether dietary intake of calcium has any impact on lead’s effects, and measured women’s diets carefully using dietary interviewers and 24 hour recall. Mothers’ mean daily calcium intake at study entry was 541 mg/24 hours; when pregnancy dietary intake of calcium was below the mean, this intensified the negative effect of maternal lead levels on infant growth, particularly birth weight.

The authors make a convincing case for biological plausibility of both the interrelationship between maternal dietary calcium intake during pregnancy and maternal blood lead levels, and the consequent demonstrated effect on infant growth. This article sets the stage for additional public health work, both to promote increased dietary calcium during pregnancy, and to continue the fight to reduce exposure of mothers and children to environmental toxins, including lead.

Wednesday, November 12, 2014

Infant Neurodevelopment After Congenital HHV-6 Infection

By: Lewis First, MD, MS; Editor-in-Chief 

HHV-6 Inclusion bodies. Photo via the US National Cancer Institute
While we usually think of human herpesvirus 6 (HHV-6) as being the virus responsible for roseola, there is much more to this virus than a simple viral exanthem. About 1 percent of infants are born with vertical transmission of HHV-6 and when this happens, the results are far more worrisome than just being at risk for a viral exanthem.

Dr. Mary Caserta and her colleagues in Rochester (doi: 10.1542/peds. 2014-0886) have been actively studying congenital HHV-6 and this month release their findings on early developmental outcomes of children who have received the virus through vertical transmission from mother to baby. The authors performed developmental testing in a prospective double-blind controlled study at four points between 4 months and 30 months of age.

The results suggest that by 1 year old, some detrimental effects on neurodevelopment can be seen in those infants infected congenitally with HHV-6 compared to controls.

Have you thought about HHV-6 as a cause for developmental delay in your patients? After reading this study, you will want to learn more about what this virus can potentially do if it is present at the time of birth. We suspect more studies will be forthcoming at a faster rate given what we are learning about this virus—and if you haven’t read much about it, this is a great study to start with. Check out the study and learn more!

Related Reading:

Friday, November 7, 2014

Talking Early and Often to Babies: Closing the Word Gap Between Mothers and Fathers

By: Lewis First, MD, MS; Editor-in-Chief 

Photo by Chris O'Brian via Flickr
A key takeaway of the recent AAP National Conference and Exhibition (NCE) meeting was the emphasis on early childhood literacy and the need to increase talking time with your infants and toddlers as much as possible to promote early brain and child development. Yet how are we doing in making this happen?

Johnson et al. (doi: 10.1542/peds. 2013-4289) report on a prospective cohort study of late preterm and term infant whose vocalizations were recorded, along with parent conversation, during their birth hospitalization and again at 44 weeks post-menstrual age and at 7 months (corrected age). The results show that mothers respond more to their baby’s vocalizations than fathers, and when parents do vocalize with their babies, there is a remarkable gender preference.

So are we happy with these findings, or can we as health care professionals do even more? How often do you talk to parents about conversing with their baby? Do you make sure the quieter parent upgrades their game, rather than let the other partner do the honors, so baby gets a balanced perspective and even more brain stimulation than just from the more vocal parent?

This article sounds off with a number of thought-provoking findings that we hope you share with new parents as they start talking with their babies. There’s a lot to talk out loud about in this study—and I hope you do (perhaps even with your infant).

Related Reading: 

Thursday, November 6, 2014

Want to Improve a Child’s Negative Self-Feelings? Try Unconditional Regard!

By: Lewis First, MD, MS; Editor-in-Chief 

Photo by Paul via Flickr
Ever see a child grow sullen after losing a game or getting a negative grade on a test? Ever see self-esteem suffer, making it harder to want to play in the next game or take that next test?

Brummelman et al. (doi: 10.1542/peds. 2013-3698) decided to see if having children reflect on how they are accepted unconditionally by a loved one could attenuate the negative self-feelings in a randomized experiment being published online this week as an early release article.

The authors had pre-teens and teens aged 11-15 years old randomly assigned as an intervention take 15 minutes to reflect on experiences of “unconditional regard”—meaning feelings that they are accepted and valued by others. Those who got low test scores in school three weeks later were then evaluated for their self-feelings. Interestingly, if students had been reflecting on their feelings of “unconditional regard”, their negativity was reduced compared to controls.

Seem too good to be true? You need to read this study and understand why we are publishing it. We hope that others will demonstrate similar findings so that reflection on one’s unconditional regard becomes more embedded into a child’s thought processes and in turn, they are better able to confront adversity and rebound positively.

Even if you don’t believe the findings in this well-done study, give the article your unconditional regard and then let us know your thoughts via a comment on this blog, an eLetter on our journal site, or on Twitter or Facebook.

Wednesday, November 5, 2014

Very Low Birth Weight Infants, Social Interventions: Two New Studies on Autism Spectrum Disorders

By: Lewis First, MD, MS; Editor-in-Chief 

Child with autism spectrum disorder.
Photo by KOMU News via Flickr
There is not a general pediatric peer-reviewed journal that has not published multiple studies on autism-spectrum disorders (ASDs) and ours is no exception. This month, we further our knowledge of ASDs by publishing two fascinating studies on this developmental abnormality.

The first by Pyhälä et al. (doi: 10.1542/peds. 2014-1097) compared slightly more than 1,000 adults born in Helsinki at very low birth weight (less than 1,500 grams) with term-born adults for ASD traits based on various developmental test batteries.

The results are well worth your attention and indicate that if children are born very low birth weight (VLBW) there is a higher risk of ASD traits as adults, especially in regard to social interactions. Although the authors note that faster growth in weight, height and head circumference from birth to term seemed to reduce this risk, suggesting that targeted interventions to aggressively grow a VLBW infant may play a role in improving an infant’s neurodevelopment as well. Just the fact that the authors have followed a cohort of VLBW infants into adulthood and tracked their developmental skills make this an interesting study to reflect upon.

A second study by Wetherby et al. (doi: 10.1542/peds.2014-0757) randomized toddlers with ASDs to receive either a parent-implemented social intervention at home or a group early social interaction program in a clinic, both designed in either case to help parents better communicate with their children in everyday activities. In this case, the results of this trial had a clear winner—the individual early social interaction program.

To find out what the program consisted of and whether it can be adapted by ASD families in your practice, review the findings in this study. Given that doing so will not require large amounts of professional time nor overwhelming amounts of parental time makes this a must-read if you care for children with ASDs.

Related Reading:

Wednesday, October 29, 2014

Association Between Perinatal Complications and Accelerated Aging at Midlife

By: Lewis First, MD, MS; Editor-in-Chief 

Public domain photo via Pixabay
We certainly have published myriads of studies noting the role of perinatal complications increasing risks for morbidity and mortality in early childhood—but what about later in life?

Can a perinatal stressful event lead to earlier aging processes in adulthood?

It’s a fascinating hypothesis that Shalev et al. (doi:10.1542/peds.2014-1669) set out to study looking at leucocyte telomere length and perceived facial age of a prospective cohort of more than 1,000 adults who have been studied since birth for 38 years. In this study, even when controlling for potential confounders, authors found an association between perinatal maternal and infant complications and subsequent aging indicators.

Just why or how this might occur is discussed by the authors and also in a thought-provoking commentary by Dr. Alan Guttmacher, director of the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), and Dr. Tonse Raju (medical program officer for the NICHD) (doi:10.1542/peds.2014-2646) that also warrants your consideration.

The idea that perinatal programming can influence how we age is a fascinating concept—but it’s even more fascinating when this study begins to show this to be true. Clearly we will need even more research in the months and years ahead to better identify the mechanisms at play that promote accelerated aging as a result of perinatal complications.

Monday, October 27, 2014

Why You Should be Thinking About Fetal Alcohol Spectrum Disorders in Your Practice

By: Lewis First, MD, MS; Editor-in-Chief 

Diagnosing someone with a fetal alcohol spectrum disorder (FASD) is easier said than done. The findings can be subtle and might be easily missed unless you uncover clues in the family history or are aware of the constellation of dysmorphology findings that can be associated with this disorder.

Sometimes there is a sense that a fetal alcohol spectrum disorder is a rarer entity than it actually is—and thus you need not worry about missing something unlikely to occur. Alternatively, you may figure it will eventually declare itself anyway if a child develops progressive development delay or another less subtle finding prompting a more careful diagnostic approach.

Yet the prevalence of fetal alcohol spectrum disorders appears to be more common than we might hope—at least according to a representative sample of children examined at ages 6 to 7 in the Midwest US as studied by May et al. (doi:10.1542/peds.2013-3319).

Figure showing final estimate of FASD prevalence in a Midwestern US city.
Copyright 2014 © American Academy of Pediatrics. Used with permission.

The researchers selected their sample simply on the basis of their being below the 25th percentile for height, weight, and head circumference. This interesting study also includes a discussion of the risk factors that might point you towards diagnosing this disorder sooner.

If you need a refresher on ways to identify fetal alcohol syndrome so you can diagnose and implement early intervention services sooner rather than later, this is the study for you.

Related Reading: