Jensen Arne, Rochow Niels, Voigt Manfred, Neuhäuser Gerhard
Campus Clinic Gynecology, Ruhr-University Bochum, Germany (Dr Jensen).
Department of Pediatrics, Paracelsus Medical University, Nuremberg, Germany (Dr Rochow).
AJOG Glob Rep. 2024 Jan 9;4(1):100305. doi: 10.1016/j.xagr.2023.100305. eCollection 2024 Feb.
Fetal growth restriction and immaturity are associated with poor neurocognitive development and child psychopathology affecting educational success at school and beyond. However, the differential effects of either obstetrical risk factor on predicted psychomotor development have not yet been deciphered.
This study aimed to separately study the impact of growth restriction and that of immaturity on predicted psychomotor development at the preschool age of 4.3 (standard deviation, 0.8) years using birthweight percentiles in a prospective cohort of preterm infants born at ≤37 weeks of gestation. Differences between small for gestational age newborns with intrauterine growth restriction and those without were described. We examined total psychomotor development score, developmental disability index, morphometric vitality index, and intelligence quotient, Porteus Maze test score, and neurologic examination optimality score in 854 preterm infants from a large prospective screening cohort (cranial ultrasound screening, n=5,301).
This was a prospective cranial ultrasound screening study with a single-center cohort observational design (data collection done from 1984-1988, analysis done in 2022). The study included 5,301 live-born infants, of whom 854 (16.1%) were preterm infants (≤37 weeks' gestation), and was conducted on the day of discharge of the mother at 5 to 8 days postpartum from a level 3 perinatal center. Predicted psychomotor development, as assessed by the total psychomotor development score, developmental disability index, morphometric vitality index, intelligence quotient, Porteus Maze test score, and neurologic examination optimality score were calculated. We related psychomotor development indices and measures to gestational age in 3 groups of birthweight percentiles (ie, 10%, 50%, and 90% for small, appropriate, and large for gestational age newborns, respectively) using linear regression analysis, analysis of variance, multivariate analysis of variance, and test procedures.
The key result of our study is the observation that in preterm infants born at ≤37 weeks of gestation, growth restriction as compared with immaturity is the prime risk factor for impairment of overall psychomotor development, intelligence quotient, Porteus Maze test results, and neurologic examination optimality score at the preschool age of 4.3 (standard deviation, 0.8) years (<.001). This is particularly true for intrauterine growth restriction. These detrimental effects of growth restriction become more prominent with decreasing gestational age (<.001). As expected, growth restriction in preterm infants born at ≤37 weeks of gestation was associated with a number of obstetrical risk factors, including hypertension in pregnancy (<.001), multiple pregnancy (<.001), pathologic cardiotocography (=.001), and low pH (=.007), increased pCO2 (=.009), and poor pO2 (<.001) in umbilical arterial blood. Of note, there were no differences in cerebral hemorrhage or white matter damage among small, appropriate, and large for gestational age birthweight percentile groups, suggesting an independent mechanism of brain injury caused by preterm growth restriction resulting in poor psychomotor development.
Compared with immaturity, growth restriction in preterm infants has more intense detrimental effects on psychomotor development, necessitating improved risk stratification. This finding has implications for clinical management, parental consultation, and early intervention strategies to improve school performance, educational success, and mental health in children. The mechanisms of brain injury specific to growth restriction in preterm infants require further elucidation.
胎儿生长受限和不成熟与神经认知发育不良及儿童精神病理学相关，会影响孩子在学校及其他方面的学业成就。然而，尚未明确这两种产科风险因素对预测的精神运动发育的不同影响。
本研究旨在利用出生体重百分位数，在前瞻性队列研究中，对孕周≤37周出生的早产儿在4.3（标准差0.8）岁学龄前分别研究生长受限和不成熟对预测的精神运动发育的影响。描述了小于胎龄且有宫内生长受限的新生儿与无宫内生长受限的新生儿之间的差异。我们在一个大型前瞻性筛查队列（头颅超声筛查，n = 5301）中的854例早产儿中，检查了总精神运动发育评分、发育残疾指数、形态活力指数、智商、波特斯迷宫测试评分和神经检查最优性评分。
这是一项采用单中心队列观察性设计的前瞻性头颅超声筛查研究（数据收集于1984 - 1988年，分析于2022年进行）。该研究纳入了5301例活产婴儿，其中854例（16.1%）为早产儿（孕周≤37周），研究在产后5至8天母亲出院当天，于三级围产中心进行。计算通过总精神运动发育评分、发育残疾指数、形态活力指数、智商、波特斯迷宫测试评分和神经检查最优性评分评估的预测精神运动发育情况。我们使用线性回归分析、方差分析、多变量方差分析和检验程序，将精神运动发育指标和测量值与3组出生体重百分位数（即小于胎龄、适于胎龄和大于胎龄新生儿的10%、50%和90%）的孕周相关联。
我们研究的关键结果是观察到，在孕周≤37周出生的早产儿中，与不成熟相比，生长受限是4.3（标准差0.8）岁学龄前总体精神运动发育、智商、波特斯迷宫测试结果和神经检查最优性评分受损的主要风险因素（P <.001）。对于宫内生长受限尤其如此。生长受限的这些有害影响随着孕周的降低而更加显著（P <.001）。正如预期的那样，孕周≤37周出生的早产儿的生长受限与多种产科风险因素相关，包括妊娠期高血压（P <.001）、多胎妊娠（P <.001）、病理性胎心监护（P =.001）以及脐动脉血中低pH值（P =.007）、pCO2升高（P =.009）和pO2降低（P <.001）。值得注意的是，小于胎龄、适于胎龄和大于胎龄出生体重百分位数组之间在脑出血或白质损伤方面没有差异，这表明早产生长受限导致精神运动发育不良存在独立的脑损伤机制。
与不成熟相比，早产儿的生长受限对精神运动发育有更强烈的有害影响，需要改进风险分层。这一发现对临床管理、家长咨询以及改善儿童学业成绩、教育成就和心理健康的早期干预策略具有重要意义。早产儿生长受限特有的脑损伤机制需要进一步阐明。
