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Early standard development assessment characteristics in very low birth weight infants later classified with autism spectrum disorder
Early Human Development 91 (2015) 357–359
Contents lists available at ScienceDirect
Early Human Development journal homepage: www.elsevier.com/locate/earlhumdev
Early standard development assessment characteristics in very low birth weight infants later classified with autism spectrum disorder Hideki Kihara a, Tomohiko Nakamura b,⁎ a b
Department of Rehabilitation, Nagano Children's Hospital, Nagano, Japan Division of Neonatology, Nagano Children's Hospital, Nagano, Japan
a r t i c l e
i n f o
Article history: Received 23 September 2014 Received in revised form 16 February 2015 Accepted 30 March 2015 Available online xxxx Keywords: Screening ASD VLBWI
a b s t r a c t Background: The prevalence of autism spectrum disorder (ASD) symptoms is high among very low birth weight infants (VLBWIs). Early diagnosis of ASD is crucial, because early intervention for ASD is effective. Objective: To evaluate early standard development assessment characteristics in VLBWIs later classified with ASD. Methods: Thirty-five VLBWIs later diagnosed with ASD were compared with 169 children with typical development who were admitted to the neonatal intensive care unit at Nagano Children's Hospital between 2001 and 2005. We retrospectively evaluated developmental quotient (DQ) using the Kyoto Scale of Psychological Development (KSPD) at 6 and 18 months post-term age (PTA) and 3 year chronological age. Results: KSPD DQ was significantly lower in ASD infants than in typical development infants at all ages. Posturalmotor DQs of ASD infants at 18 months PTA and 3 year chronological age showed some increase compared to that at 6 months PTA. Conclusion: Early recognition of ASD using standardized development assessment tools in VLBWIs might be possible. © 2015 Elsevier Ireland Ltd. All rights reserved.
1. Introduction Advances in neonatal intensive care have dramatically increased survival for preterm infants in Japan. Unfortunately, this decrease in mortality has not been matched by comparable decreases in longterm neurodevelopmental morbidity, cerebral palsy (CP), or intellectual disability (ID) [1–7]. Most previous investigations into outcomes for very low birth weight infants (VLBWIs) have focused on severe disability, such as CP with or without associated ID [1,2,4,5,8,9]. Low birth weight and gestational age have recently been identified in several studies as important perinatal risk factors for disturbances in social interaction, communication, and behavior. In addition, a higher prevalence of autism spectrum disorder (ASD) symptoms later in childhood has been reported in association with obstetric and neonatal factors [10–16]. Clinically, identifying factors allowing the early diagnosis of ASD is crucial, because early intervention for ASD has been shown to be effective. Although many studies have identified clinical risk factors for later diagnoses of CP [17], ID, and ASD, few have reported early screening of VLBWIs who later received a diagnosis of ASD [15,18,19]. Identification of early behavioral risk factors could provide a major contribution toward improving outcomes through earlier detection and intervention. ⁎ Corresponding author at: Division of Neonatology, Nagano Children's Hospital, 3100 Toyoshina, Azumino, Nagano 399-8288, Japan. Tel.: +81 263 73 6700; fax: +81 263 73 5432. E-mail address: [email protected] (T. Nakamura).
http://dx.doi.org/10.1016/j.earlhumdev.2015.03.012 0378-3782/© 2015 Elsevier Ireland Ltd. All rights reserved.
The aim of this report was to retrospectively evaluate early developmental characteristics in infants who later received a diagnosis of ASD from standardized assessments of development. 2. Methods Ethical approval was obtained from the ethics committee at Nagano Children's Hospital. Informed consent was obtained from the parents of each infant prior to participation. 2.1. Participants The neonatal intensive care unit (NICU) at Nagano Children's Hospital is the only level III unit within the province of Nagano, and covers a population of about 2 million people. Of 421 VLBWIs admitted to the NICU between June 2001 and December 2005, 34 infants died during the NICU stay, 66 infants were transferred to a local level II unit for follow-up, and 321 infants were enrolled into a domestic follow-up program for VLBWIs at the time of discharge. Health histories and performances on tests administered at 6 months post-term age (PTA), 18 months PTA, and 3 and 6 year chronological ages using individualized assessment tools were investigated. Infants who had low assessment scores were picked up at 3 years. A pediatric neurologist examined them and got information from their parents and kindergarten teachers. Then, 35 children (Group A) were diagnosed with ASD at 3–6 years old in accordance with the criteria of
H. Kihara, T. Nakamura / Early Human Development 91 (2015) 357–359
358
the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV). One hundred sixty-nine typical development children (Group B) who showed a full-scale intelligence quotient (IQ) N 79 in the Wechsler Intelligence Scale for Children, third edition (WISC III) at a chronological age of 6 years were used as controls for comparison with Group A. Among the 321 infants enrolled, 42 infants missed the assessment and other 75 infants showed atypical development and/or CP at 6 years old.
3.2. KSPD scores (Table 2) KSPD DQs at 6 and 18 months PTA and 3 year chronological age are summarized in Table 2. KSPD DQs at all ages were significantly lower in Group A than in Group B. However, P-M DQs of Group A at 18 months PTA and 3 year chronological age showed some increase compared to that at 6 months PTA. 4. Discussion
2.2. Follow-up evaluation Neurodevelopmental outcomes at 6 and 18 months PTA and 3 year chronological age were evaluated using the Kyoto Scale of Psychological Development (KSPD). The KSPD examines general developmental progress and delay in three domains: postural-motor (P-M); cognitiveadaptive (C-A); and language-social (L-S). In each of these three areas, developmental quotient (DQ) was calculated by dividing the developmental age by the chronological age and then multiplying the resulting quotient by 100. According to the protocol for this follow-up study, developmental function was classified as “delayed” for DQ b 70, “borderline” for DQ = 70–84, and “normal” for DQ N 84. At a chronological age of 6 years, the WISC III was administered by an experienced psychologist to assess verbal, performance, and fullscale IQs. Developmental function was classified as “delayed” for fullscale IQ b 70, “borderline” for IQ = 70–79, and “normal” for IQ N 79. At the same times, parents were also asked whether their children required any special assistance at kindergarten because of problems with social, emotional, or behavioral adaptation using the modified “Childhood Autism Rating Scale”.
2.3. Statistical analysis We used the Kruskal–Wallis test and Steel's test as a multiple comparison procedure to compare KSPD scores at 6 and 18 months PTA and 3 year chronological age between Groups A and B. Statistical significance was defined as a two-sided value of P b 0.05.
3. Results 3.1. Clinical characteristics (Table 1) The clinical characteristics of the two groups are shown in Table 1. Gestational age, birth weight, and Apgar score at 1 min were lower in Group A children than in Group B infants. The proportion of male infants was larger in Group A.
Table 1 Characteristics of the study population.
Sex (male:female) Gestational age at delivery (weeks) Birth weight (g) Apgar score (1 min) Apgar score (5 min) Length of NICU stay (days) Disease in neonatal period SGA CLD ROP IVH PVL
Group A (n = 35)
Group B (n = 169)
22:13 27.4 (25.1–30.5) 951 (726–1219) 4 (3–6) 7 (6–8) 59 (80–120)
63:106 29.2 (27.3–31.3) 1162 (888–1335) 6 (4–7) 8 (7–9) 72 (51–92)
11 (31) 3 (9) 20 (57) 5 (14) 2 (6)
20 (12) 36 (20) 70 (41) 7 (4) 2 (1)
Data are presented as median (interquartile range) or number (percentage). SGA, small-for-gestational-age; CLD, chronic lung disease; ROP, retinopathy of prematurity; IVH, intraventricular hemorrhage; and PVL, periventricular leukomalacia.
We have previously reported gestational age and birth weight as significant risk factors for neurodevelopmental outcomes of VLBWIs at 18 months PTA [9]. We have also reported that the appearance of abnormal white matter on term MRI showed a consistent association with cognitive impairment, such as cerebral palsy and the need for special assistance at school [8]. A review by Aamoudse-Moens [20] found that very preterm and/or VLBW children often show moderate to severe deficits in academic achievement, attention problems, internalizing behavioral problems and executive function problems. A French group [21] also reported epidemiological results indicating that children born very preterm need a high level of specialized care due to learning disabilities with cognitive deficiencies. Low birth weight and gestational age have recently been identified in several studies as important perinatal risk factors for disturbances in social interaction, communication, and behavior, as well as ASD symptoms later in childhood. In this study, we found that ASD infants showed a different KSPD domain DQ at 6 months PTA. However, P-M DQs of ASD infants at 18 months PTA and 3 year chronological age showed some increase compared to that at 6 months PTA. Autism is thought to typically not be recognized before 2 years of age, but a broad spectrum of neuroanatomical abnormalities has been reported in children with autism. Asymmetric visual tracking and abnormal tone of the upper extremity at 1 month PTA might represent very early markers of ASD [18]. Unusual visual function has been reported in older infants and children with ASD. Klin et al. [22,23] reported that the absence of preferential looking to the eyes of an approaching adult in 2-year-old toddlers with ASD is related to an increased level of social disability and impaired recognition of biological motion as early as 15 months. Social, communication, and language developments are also expected to represent early precursors of ASD. The presence of reduced language ability among children born preterm has been well-described [24,25]. Whether such findings are more specific to ASD or are similarly associated with other developmental disorders such as ID remains unclear. We therefore suggest that total standardized development assessments are important for recognizing
Table 2 KSPD DQ scores at 6 and 18 months post-term age (PTA) and 3 year chronological age in groups. Age
KSPD
Group A (n = 35)
Group B (n = 169)
6M
P-M C-A L-S Total P-M C-A L-S Total P-M C-A L-S Total
84 (71–94) ⁎⁎ 89 (76–101) ⁎⁎ 90 (79–101) ⁎⁎ 89 (75–97) ⁎⁎ 90 (80–97)⁎ 78 (72–89) ⁎⁎ 78 (68–94) ⁎⁎ 82 (73–89) ⁎⁎ 100 (67–103) ⁎ 80 (68–86) ⁎⁎ 78 (67–86) ⁎⁎ 80 (70–86) ⁎⁎
93 (84–106) 102 (94–110) 103 (91–115) 99 (91–109) 98 (91–108) 99 (91–107) 97 (93–108) 99 (92–106) 103 (100–103) 100 (92–106) 96 (89–103) 97 (91–103)
18M
3Y
Data are presented as median (interquartile range). KSPD DQ, Kyoto Scale of Psychological Development 2001 developmental quotient; 6M, 6 months post-term age; 18M, 18 months post-term age; 3Y, 3 year chronological age; P-M, postural-motor; C-A, cognitive-adaptive; and L-S, language-social. ⁎ P b 0.05; Group A vs. Group B. ⁎⁎ P b 0.01; Group A vs. Group B.
H. Kihara, T. Nakamura / Early Human Development 91 (2015) 357–359
ASD and distinguishing between other developmental disorders in VLBWIs. In conclusion, we showed characteristic developmental patterns at 6 and 18 months PTA and 3 year chronological age in VLBWIs later diagnosed with ASD using standardized development assessment tools. Early recognition of ASD using standardized development assessment tools in VLBWIs appears possible. Contributions Kihara H: Participated in the design of the study and performed the statistical analysis. Nakamura T: Conceived the study, participated in its design and coordination, and wrote the first draft of the manuscript. Conflict of interest The authors have no conflicts of interest to declare in relation to this work. Acknowledgments This study was funded by a grant for scientific research from Ministry of Health, Labour and Welfare, Japan. References [1] Ishii N, Kono Y, Yonemoto N, Kusuda S, Fujimura M, Neonatal Research Network, Japan. Outcomes of infants born at 22 and 23 weeks' gestation. Pediatrics 2013; 132:62–71. [2] Isayama T, Lee SK, Mori R, Kusuda S, Fujimura M, Ye XY, et al. Comparison of mortality and morbidity of very low birth weight infants between Canada and Japan. Pediatrics 2012;130:e957–65. [3] Kusuda S, Fujimura M, Uchiyama A, Totsu S, Matsunami K, Neonatal Research Network, Japan. Trends in morbidity and mortality among very-low-birth-weight infants from 2003 to 2008 in Japan. Pediatr Res 2012;72:531–8. [4] Kono Y, Mishina J, Yonemoto N, Kusuda S, Fujimura M. Outcomes of very-lowbirthweight infants at 3 years of age born in 2003–2004 in Japan. Pediatr Int 2011;53:1051–8. [5] Kono Y, Mishina J, Yonemoto N, Kusuda S, Fujimura M, NICU Network, Japan. Neonatal correlates of adverse outcomes in very low-birthweight infants in the NICU Network. Pediatr Int 2011;53:930–5. [6] Mori R, Kusuda S, Fujimura M, Neonatal Research Network Japan. Antenatal corticosteroids promote survival of extremely preterm infants born at 22 to 23 weeks of gestation. J Pediatr 2011;159:110–4. [7] Itabashi K, Horiuchi T, Kusuda S, Kabe K, Itani Y, Nakamura T, et al. Mortality rates for extremely low birth weight infants born in Japan in 2005. Pediatrics 2009;123: 445–50.
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[8] Iwata S, Nakamura T, Hizume E, Kihara H, Takahashi S, Matsuishi T, et al. Qualitative brain MRI at term and cognitive outcomes at 9 years old after very preterm birth. Pediatrics 2012;129:e1138–47. [9] Tamaru S, Kikuchi A, Takagi K, Wakamatsu M, Ono K, Horikoshi T, et al. Neurodevelopmental outcomes of very low birth weight and extremely low birth weight infants at 18 months of corrected age associated with prenatal risk factors. Early Hum Dev 2011;87:55–9. [10] Bryson SE, Zwaigenbaum L, Brian J, Roberts W, Szatmari P, Rombough V, et al. A prospective case series of high-risk infants who developed autism. J Autism Dev Disord 2007;37:12–24. [11] Johnson S, Hollis C, Kochhar P, Hennessy E, Wolke D, Marlow N. Autistic spectrum disorders in extremely preterm children. J Pediatr 2010;156:525–31. [12] Kolevzon A, Gross R, Reichenberg A. Prenatal and perinatal risk factors for autism: a review and integration of findings. Arch Pediatr Adolesc Med 2007;161:326–33. [13] Kuban KC, O'Shea TM, Allred EN, Tager-Flusberg H, Goldstein DJ, Leviton A. Positive screening on the Modified Checklist for Autism in Toddlers (M-CHAT) in extremely low gestational age newborns. J Pediatr 2009;154:535–40. [14] Limperopoulos C, Bassan H, Gauvreau K, Robertson Jr RL, Sullivan NR, Benson CB, et al. Does cerebellar injury in premature infants contribute to the high prevalence of long-term cognitive, learning, and behavioral disability in survivors? Pediatrics 2007;120:584–93. [15] Limperopoulos C, Bassan H, Sullivan NR, Soul JS, Robertson Jr RL, Moore M, et al. Positive screening for autism in ex-preterm infants: prevalence and risk factors. Pediatrics 2008;121:758–65. [16] Schendel DE, Bhasin TK. Birth weight and gestational age characteristics of children with autism, including a comparison with other developmental disabilities. Pediatrics 2008;121:1155–64. [17] Kanemaru N, Watanabe H, Kihara H, Nakano H, Takaya R, Nakamura T, et al. Specific characteristic of spontaneous movements in preterm infants at term age are associated with developmental delays at age 3 years. Dev Med Child Neurol 2013;55:713–21. [18] Karmel BZ, Gardner JM, Meade LS, Cohen IL, London E, Flory MJ, et al. Early medical and behavioral characteristics of NICU infants later classified with ASD. Pediatrics 2010;126:457–67. [19] Johnson S, Hollis C, Hennessy E, Kochhar P, Wolke D, Marlow N. Screening for autism in preterm children: diagnostic utility of Social Communication Questionnaire. Arch Dis Child 2011;96:73–7. [20] Aamoudse-Moens CS, Weisglas-Kuperus N, van Goudoever JB, Oosterlaan J. Metaanalysis of neurobehavioral outcomes in very preterm and/or very low birth weight children. Pediatrics 2009;124:717–28. [21] Larroque B, Ancel PY, Marret S, Marchand L, André M, Arnaud C, et al. Neurodevelopmental disabilities and special care of 5-year-old children born before 33 weeks of gestation (the EPIPAGE study): a longitudinal cohort study. Lancet 2008;371:813–20. [22] Klin A, Lin DJ, Gorrindo P, Ramsey G, Jones W. Two-year-olds with autism orient to non-social contingencies rather than biological motion. Nature 2009;459:257–61. [23] Klin A, Jones W. Altered face scanning and impaired recognition of biological motion in a 15-month-old infant with autism. Dev Sci 2008;11:40–6. [24] van Noort-van der Spek IL, Franken MC, Weisglas-Kuperus N. Language functions in preterm-born children: a systematic review and meta-analysis. Pediatrics 2012;129: 745–54. [25] Barre N, Morgan A, Doyle LW, Anderson PJ. Language abilities in children who were very preterm and/or very low birth weight: a meta-analysis. J Pediatr 2011;158: 766–74.
Contents lists available at ScienceDirect
Early Human Development journal homepage: www.elsevier.com/locate/earlhumdev
Early standard development assessment characteristics in very low birth weight infants later classified with autism spectrum disorder Hideki Kihara a, Tomohiko Nakamura b,⁎ a b
Department of Rehabilitation, Nagano Children's Hospital, Nagano, Japan Division of Neonatology, Nagano Children's Hospital, Nagano, Japan
a r t i c l e
i n f o
Article history: Received 23 September 2014 Received in revised form 16 February 2015 Accepted 30 March 2015 Available online xxxx Keywords: Screening ASD VLBWI
a b s t r a c t Background: The prevalence of autism spectrum disorder (ASD) symptoms is high among very low birth weight infants (VLBWIs). Early diagnosis of ASD is crucial, because early intervention for ASD is effective. Objective: To evaluate early standard development assessment characteristics in VLBWIs later classified with ASD. Methods: Thirty-five VLBWIs later diagnosed with ASD were compared with 169 children with typical development who were admitted to the neonatal intensive care unit at Nagano Children's Hospital between 2001 and 2005. We retrospectively evaluated developmental quotient (DQ) using the Kyoto Scale of Psychological Development (KSPD) at 6 and 18 months post-term age (PTA) and 3 year chronological age. Results: KSPD DQ was significantly lower in ASD infants than in typical development infants at all ages. Posturalmotor DQs of ASD infants at 18 months PTA and 3 year chronological age showed some increase compared to that at 6 months PTA. Conclusion: Early recognition of ASD using standardized development assessment tools in VLBWIs might be possible. © 2015 Elsevier Ireland Ltd. All rights reserved.
1. Introduction Advances in neonatal intensive care have dramatically increased survival for preterm infants in Japan. Unfortunately, this decrease in mortality has not been matched by comparable decreases in longterm neurodevelopmental morbidity, cerebral palsy (CP), or intellectual disability (ID) [1–7]. Most previous investigations into outcomes for very low birth weight infants (VLBWIs) have focused on severe disability, such as CP with or without associated ID [1,2,4,5,8,9]. Low birth weight and gestational age have recently been identified in several studies as important perinatal risk factors for disturbances in social interaction, communication, and behavior. In addition, a higher prevalence of autism spectrum disorder (ASD) symptoms later in childhood has been reported in association with obstetric and neonatal factors [10–16]. Clinically, identifying factors allowing the early diagnosis of ASD is crucial, because early intervention for ASD has been shown to be effective. Although many studies have identified clinical risk factors for later diagnoses of CP [17], ID, and ASD, few have reported early screening of VLBWIs who later received a diagnosis of ASD [15,18,19]. Identification of early behavioral risk factors could provide a major contribution toward improving outcomes through earlier detection and intervention. ⁎ Corresponding author at: Division of Neonatology, Nagano Children's Hospital, 3100 Toyoshina, Azumino, Nagano 399-8288, Japan. Tel.: +81 263 73 6700; fax: +81 263 73 5432. E-mail address: [email protected] (T. Nakamura).
http://dx.doi.org/10.1016/j.earlhumdev.2015.03.012 0378-3782/© 2015 Elsevier Ireland Ltd. All rights reserved.
The aim of this report was to retrospectively evaluate early developmental characteristics in infants who later received a diagnosis of ASD from standardized assessments of development. 2. Methods Ethical approval was obtained from the ethics committee at Nagano Children's Hospital. Informed consent was obtained from the parents of each infant prior to participation. 2.1. Participants The neonatal intensive care unit (NICU) at Nagano Children's Hospital is the only level III unit within the province of Nagano, and covers a population of about 2 million people. Of 421 VLBWIs admitted to the NICU between June 2001 and December 2005, 34 infants died during the NICU stay, 66 infants were transferred to a local level II unit for follow-up, and 321 infants were enrolled into a domestic follow-up program for VLBWIs at the time of discharge. Health histories and performances on tests administered at 6 months post-term age (PTA), 18 months PTA, and 3 and 6 year chronological ages using individualized assessment tools were investigated. Infants who had low assessment scores were picked up at 3 years. A pediatric neurologist examined them and got information from their parents and kindergarten teachers. Then, 35 children (Group A) were diagnosed with ASD at 3–6 years old in accordance with the criteria of
H. Kihara, T. Nakamura / Early Human Development 91 (2015) 357–359
358
the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV). One hundred sixty-nine typical development children (Group B) who showed a full-scale intelligence quotient (IQ) N 79 in the Wechsler Intelligence Scale for Children, third edition (WISC III) at a chronological age of 6 years were used as controls for comparison with Group A. Among the 321 infants enrolled, 42 infants missed the assessment and other 75 infants showed atypical development and/or CP at 6 years old.
3.2. KSPD scores (Table 2) KSPD DQs at 6 and 18 months PTA and 3 year chronological age are summarized in Table 2. KSPD DQs at all ages were significantly lower in Group A than in Group B. However, P-M DQs of Group A at 18 months PTA and 3 year chronological age showed some increase compared to that at 6 months PTA. 4. Discussion
2.2. Follow-up evaluation Neurodevelopmental outcomes at 6 and 18 months PTA and 3 year chronological age were evaluated using the Kyoto Scale of Psychological Development (KSPD). The KSPD examines general developmental progress and delay in three domains: postural-motor (P-M); cognitiveadaptive (C-A); and language-social (L-S). In each of these three areas, developmental quotient (DQ) was calculated by dividing the developmental age by the chronological age and then multiplying the resulting quotient by 100. According to the protocol for this follow-up study, developmental function was classified as “delayed” for DQ b 70, “borderline” for DQ = 70–84, and “normal” for DQ N 84. At a chronological age of 6 years, the WISC III was administered by an experienced psychologist to assess verbal, performance, and fullscale IQs. Developmental function was classified as “delayed” for fullscale IQ b 70, “borderline” for IQ = 70–79, and “normal” for IQ N 79. At the same times, parents were also asked whether their children required any special assistance at kindergarten because of problems with social, emotional, or behavioral adaptation using the modified “Childhood Autism Rating Scale”.
2.3. Statistical analysis We used the Kruskal–Wallis test and Steel's test as a multiple comparison procedure to compare KSPD scores at 6 and 18 months PTA and 3 year chronological age between Groups A and B. Statistical significance was defined as a two-sided value of P b 0.05.
3. Results 3.1. Clinical characteristics (Table 1) The clinical characteristics of the two groups are shown in Table 1. Gestational age, birth weight, and Apgar score at 1 min were lower in Group A children than in Group B infants. The proportion of male infants was larger in Group A.
Table 1 Characteristics of the study population.
Sex (male:female) Gestational age at delivery (weeks) Birth weight (g) Apgar score (1 min) Apgar score (5 min) Length of NICU stay (days) Disease in neonatal period SGA CLD ROP IVH PVL
Group A (n = 35)
Group B (n = 169)
22:13 27.4 (25.1–30.5) 951 (726–1219) 4 (3–6) 7 (6–8) 59 (80–120)
63:106 29.2 (27.3–31.3) 1162 (888–1335) 6 (4–7) 8 (7–9) 72 (51–92)
11 (31) 3 (9) 20 (57) 5 (14) 2 (6)
20 (12) 36 (20) 70 (41) 7 (4) 2 (1)
Data are presented as median (interquartile range) or number (percentage). SGA, small-for-gestational-age; CLD, chronic lung disease; ROP, retinopathy of prematurity; IVH, intraventricular hemorrhage; and PVL, periventricular leukomalacia.
We have previously reported gestational age and birth weight as significant risk factors for neurodevelopmental outcomes of VLBWIs at 18 months PTA [9]. We have also reported that the appearance of abnormal white matter on term MRI showed a consistent association with cognitive impairment, such as cerebral palsy and the need for special assistance at school [8]. A review by Aamoudse-Moens [20] found that very preterm and/or VLBW children often show moderate to severe deficits in academic achievement, attention problems, internalizing behavioral problems and executive function problems. A French group [21] also reported epidemiological results indicating that children born very preterm need a high level of specialized care due to learning disabilities with cognitive deficiencies. Low birth weight and gestational age have recently been identified in several studies as important perinatal risk factors for disturbances in social interaction, communication, and behavior, as well as ASD symptoms later in childhood. In this study, we found that ASD infants showed a different KSPD domain DQ at 6 months PTA. However, P-M DQs of ASD infants at 18 months PTA and 3 year chronological age showed some increase compared to that at 6 months PTA. Autism is thought to typically not be recognized before 2 years of age, but a broad spectrum of neuroanatomical abnormalities has been reported in children with autism. Asymmetric visual tracking and abnormal tone of the upper extremity at 1 month PTA might represent very early markers of ASD [18]. Unusual visual function has been reported in older infants and children with ASD. Klin et al. [22,23] reported that the absence of preferential looking to the eyes of an approaching adult in 2-year-old toddlers with ASD is related to an increased level of social disability and impaired recognition of biological motion as early as 15 months. Social, communication, and language developments are also expected to represent early precursors of ASD. The presence of reduced language ability among children born preterm has been well-described [24,25]. Whether such findings are more specific to ASD or are similarly associated with other developmental disorders such as ID remains unclear. We therefore suggest that total standardized development assessments are important for recognizing
Table 2 KSPD DQ scores at 6 and 18 months post-term age (PTA) and 3 year chronological age in groups. Age
KSPD
Group A (n = 35)
Group B (n = 169)
6M
P-M C-A L-S Total P-M C-A L-S Total P-M C-A L-S Total
84 (71–94) ⁎⁎ 89 (76–101) ⁎⁎ 90 (79–101) ⁎⁎ 89 (75–97) ⁎⁎ 90 (80–97)⁎ 78 (72–89) ⁎⁎ 78 (68–94) ⁎⁎ 82 (73–89) ⁎⁎ 100 (67–103) ⁎ 80 (68–86) ⁎⁎ 78 (67–86) ⁎⁎ 80 (70–86) ⁎⁎
93 (84–106) 102 (94–110) 103 (91–115) 99 (91–109) 98 (91–108) 99 (91–107) 97 (93–108) 99 (92–106) 103 (100–103) 100 (92–106) 96 (89–103) 97 (91–103)
18M
3Y
Data are presented as median (interquartile range). KSPD DQ, Kyoto Scale of Psychological Development 2001 developmental quotient; 6M, 6 months post-term age; 18M, 18 months post-term age; 3Y, 3 year chronological age; P-M, postural-motor; C-A, cognitive-adaptive; and L-S, language-social. ⁎ P b 0.05; Group A vs. Group B. ⁎⁎ P b 0.01; Group A vs. Group B.
H. Kihara, T. Nakamura / Early Human Development 91 (2015) 357–359
ASD and distinguishing between other developmental disorders in VLBWIs. In conclusion, we showed characteristic developmental patterns at 6 and 18 months PTA and 3 year chronological age in VLBWIs later diagnosed with ASD using standardized development assessment tools. Early recognition of ASD using standardized development assessment tools in VLBWIs appears possible. Contributions Kihara H: Participated in the design of the study and performed the statistical analysis. Nakamura T: Conceived the study, participated in its design and coordination, and wrote the first draft of the manuscript. Conflict of interest The authors have no conflicts of interest to declare in relation to this work. Acknowledgments This study was funded by a grant for scientific research from Ministry of Health, Labour and Welfare, Japan. References [1] Ishii N, Kono Y, Yonemoto N, Kusuda S, Fujimura M, Neonatal Research Network, Japan. Outcomes of infants born at 22 and 23 weeks' gestation. Pediatrics 2013; 132:62–71. [2] Isayama T, Lee SK, Mori R, Kusuda S, Fujimura M, Ye XY, et al. Comparison of mortality and morbidity of very low birth weight infants between Canada and Japan. Pediatrics 2012;130:e957–65. [3] Kusuda S, Fujimura M, Uchiyama A, Totsu S, Matsunami K, Neonatal Research Network, Japan. Trends in morbidity and mortality among very-low-birth-weight infants from 2003 to 2008 in Japan. Pediatr Res 2012;72:531–8. [4] Kono Y, Mishina J, Yonemoto N, Kusuda S, Fujimura M. Outcomes of very-lowbirthweight infants at 3 years of age born in 2003–2004 in Japan. Pediatr Int 2011;53:1051–8. [5] Kono Y, Mishina J, Yonemoto N, Kusuda S, Fujimura M, NICU Network, Japan. Neonatal correlates of adverse outcomes in very low-birthweight infants in the NICU Network. Pediatr Int 2011;53:930–5. [6] Mori R, Kusuda S, Fujimura M, Neonatal Research Network Japan. Antenatal corticosteroids promote survival of extremely preterm infants born at 22 to 23 weeks of gestation. J Pediatr 2011;159:110–4. [7] Itabashi K, Horiuchi T, Kusuda S, Kabe K, Itani Y, Nakamura T, et al. Mortality rates for extremely low birth weight infants born in Japan in 2005. Pediatrics 2009;123: 445–50.
359
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