Abnormal findings on neonatal cranial ultrasound associated with adverse neurobehaviour outcomes in neonates born prior to 30 weeks gestation

1. White matter lesions on neonatal cranial ultrasound in neonates born prior to 30 weeks gestation were associated with the following neurobehavioral changes: lower attention, hypotonicity, poor movement quality.

Level of Evidence Rating: 2 (Good)

Study Rundown: Preterm birth is a common pregnancy complication which may predispose neonates to a number of developmental health challenges. These risks are particularly pronounced amongst infants born prior to 32 weeks gestational age, amongst whom nearly 1 in 5 are diagnosed with moderate to severe neurodevelopmental impairment. Identification of infants at risk of neurodevelopmental impairment and the provision of early intervention to improve outcomes is of paramount importance in this population. This study seeks to describe the role of neonatal cranial ultrasound (CU) in identifying brain abnormalities associated with altered neurobehavior in neonates. Infants born prior to 30 weeks gestation were compared in a prospective manner to an age-matched cohort. The total sample size of this study was 704 infants, including 679 who were assessed using the NICU Network Neurobehavioral Scale (NNNS). 658 participants had a CU performed within 1 week of birth in the NICU.  Patients with evidence of white matter injury on ultrasound were more likely to be diagnosed with chronic lung disease (CLD) and severe retinopathy of prematurity (ROP) than those who did not. This group was also at greater risk of hypotonicity, shorter attention span, and poor movement quality. Patients with generalized lesions on neonatal cranial ultrasound were found to be at risk of CLD, ROP as well as neonatal sepsis, low attention, increased lethargy and hypotonicity. This study demonstrated that white matter lesions, and abnormal findings on neonatal cranial ultrasound in general, are associated with an increased risk of neurobehavioral consequences in infants born prior to 30 weeks gestation. Strengths of this study include the large sample size and high reliability of CU due to multiple, masked assessors. A primary limitation of this study is the short follow up period; additionally, the heterogeneity of the included participants may render it difficult to apply the findings of this study to a clinical setting directly. Future research should focus on describing methods for effective early intervention in patients to reduce the burden of neurobehavioral consequences later in life.

Click to read this study in JAMA Network Open

Relevant reading: Nurturing the preterm infant brain: leveraging neuroplasticity to improve neurobehavioral outcomes

In-depth [prospective cohort study]: This prospective cohort study was conducted at 9 university-affiliated hospitals in the United States. Neonates born prior to 30 weeks gestational age who lived within a 3-hour commute of the neonatal intensive care unit (NICU) and whose parents spoke either English or Spanish were eligible for inclusion. Exclusion criteria included young maternal age (<18 years) and maternal cognitive impairment or death, as well as infant congenital anomalies or death in the NICU. Data for this study were obtained through review of medical records, cranial ultrasonography performed in the NICU and the NNNS to assess neurobehavior.

Patients with evidence of white matter injury on ultrasound were more likely to be diagnosed with chronic lung disease (69.7% vs. 47.9%) and severe retinopathy of prematurity (11.8% vs. 5.2%) than those who did not. Neurobehavioral survey revealed that patients with white matter injury were also more likely to have shorter attention spans (adjusted mean score difference -0.346, confidence interval -0.609 to -0.083), hypotonicity (0.358, 0.055 to 0.662) and poor movement quality (-0.344, −0.572 to −0.116). The risk difference in patients who did versus did not have any lesions on neonatal cranial ultrasound for several poor outcomes is as follows: CLD (64.7% vs. 45.4%), retinopathy of prematurity (11.5% vs. 4.2%), neonatal sepsis (17.9% vs. 11.2%), low attention (adjusted mean difference -0.233, -0.423 to -0.044) and hypotonicity (0.240, 0.014 to 0.465).

Image: PD

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