Young adult outcomes of very-low-birth-weight children

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Summary

Information on the young adult outcomes of the initial survivors of neonatal intensive care has been reported from the United States, Canada, Australia, Great Britain and other European countries. The studies have varied with regard to whether they were regional or hospital-based, their birth-weight group and gestational age, rates of survival, socio-demographic background, and measures of assessment and types of outcome studied. Despite these differences the overall results reveal that neurodevelopment and growth sequelae persist to young adulthood. Very-low-birth-weight young adults have, with few exceptions, poorer educational achievement than normal-birth-weight controls, and fewer continue with post-high-school study. Rates of employment are, however, similar. There are no major differences in general health status, but the young adults demonstrate poorer physical abilities, higher mean blood pressure and poorer respiratory function. There is no evidence of major psychiatric disorder, although anxiety and depression are reported more often. The young adults report less risk-taking than control populations. They report fairly normal social lives and quality of life. When differences are noted they are usually due to neurosensory disabilities. Longer-term studies are needed to evaluate ultimate educational and occupational achievement. It will also be important to assess the effects of preterm birth, early growth failure and catch-up growth on later metabolic and cardiovascular health.

Introduction

Prior to the 1950s, when few preterm infants survived, the majority of survivors to adulthood who were born with very low birth weight (VLBW, <1.5 kg) were described as having average development and normal function.1, 2 However, neonatal therapies introduced between 1950 and 1960, such as the overuse of oxygen and antibiotics to prevent infection, resulted in poorer outcomes with high rates of neurosensory deficits, including cerebral palsy, blindness and deafness.3 There were significant improvements in the survival of VLBW infants and a decrease in the rates of neurodevelopmental sequelae after the introduction of modern methods of neonatal intensive care in the 1960s.4 By the 1970s, 80–90% of VLBW children were reported to be free from serious handicap during early childhood; however, other problems became evident during the school-age and adolescent years. They included poorer cognitive function and academic performance when compared to normal-birth-weight (NBW) controls. This was evident even among VLBW children who were free of neurologic handicaps and had normal intelligence.5 The associated school learning problems resulted in higher rates of special education assistance and grade repetition for VLBW children. Chronic health problems were also more prevalent and included those associated with cerebral palsy, asthma, and visual and hearing impairments. The health problems also led to functional limitations, among them restriction in physical activities, inability to participate in sports, and visual difficulties. The majority of VLBW children also experienced poorer growth attainment, although some catch-up growth occurred during childhood. Additional problems evident during the school age and adolescent years include behavioral problems: mainly hyperactivity and attentional weaknesses, but also shyness and withdrawn behavior, difficulty in social skills, and anxiety and depression. These developmental, behavioral and health problems led to concern as to how the increasing numbers of VLBW infants, who survived as a result of neonatal intensive care in the 1970s and 1980s, would function as they approached adulthood.

Predictors of the poorer outcomes of VLBW survivors during childhood and adolescence include social and/or environmental risk factors, together with the biologic risk factors: male sex and complications of prematurity, specifically periventricular hemorrhage and/or periventricular leucomalacia (PVL), chronic lung disease, infection, and subnormal brain growth. Neuropathologic and magnetic resonance imaging (MRI) correlates of brain injury include PVL and lesser degrees of brain damage. Also relevant to the adult outcomes of VLBW infants is the current interest in the origins of adult disease during early life. Based on epidemiologic studies, it has been hypothesized that adaptations made by the fetus or young infant when undernourished may have long-term effects on health and result in mental illness, hypertension, atherosclerosis, diabetes, central obesity and death due to cardiovascular disease in middle age.6 Subjects who grow rapidly and demonstrate catch-up growth are considered at greatest risk for the medical complications.7 However, socioeconomic (SES) conditions, life style and environmental factors both in childhood and adulthood may be as important in causing adult disease as factors in utero or in infancy.8

The initial survivors of neonatal intensive care born in the 1970s reached young adulthood in the mid-1990s. Since that time, increasing numbers of studies have reported on their health and overall functioning as young adults. This paper reviews current knowledge concerning the outcomes of VLBW children who have survived to adulthood as a result of the modern methods of neonatal intensive care.4

Section snippets

Considerations in the evaluation of adult outcome studies

Considerations in evaluating the adult outcomes of neonatal intensive care include the variation in the countries of origin of the participants, their birth-weight subgroup, sociodemographic status, sample size, as well as the types of outcomes studied and the methods used (see Table 1, Table 2). Some reports include data extracted from national databases,9 others are regional,10, 11 and others hospital-based.12, 13, 14, 15 Some include only males and only singleton births.9 Others include

Review of late adolescent and young adult studies of VLBW children

Studies of various aspects of late adolescent and young adult outcomes of VLBW children born during the years 1971 and 1986 have been reported from the United States,12 Canada,10, 11, 13, 26 England,15, 17 Australia,14 Denmark,16, 18, 27 Norway28 and Sweden.9 Table 1 describes the populations and methods of the various studies, and Table 2 lists the outcomes studied.

Conclusions

The diverse results of the adult follow-up studies summarized in this review provide a societal life-time perspective of the consequences of preterm birth for VLBW and ELBW young adults who survived as a result of methods of neonatal intensive care introduced in the 1960s and 1970s. Although there are differences between studies, the results reveal that the neurodevelopmental and growth-related sequelae of very low and extremely low birth weight persist into young adulthood. VLBW and ELBW

Acknowledgements

This work was supported by grants (RO1 HD34177 and M01 RR00080, General Clinical Research Center) of the National Institutes of Health.

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