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OBJECTIVE: To evaluate changes in prevalence and severity of cerebral palsy (CP) among surviving children born at <27 weeks of gestation over time and to determine associations between CP and other developmental domains, functional impairment, medical morbidities, and resource use among 2-year-old children who were born extremely preterm. STUDY DESIGN: Retrospective cohort study using prospective registry data, conducted at 25 centers of the Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network. Participants were children born at <27 weeks of gestation and followed at 18 through 26 months of corrected age from 2008 through 2019. Outcomes of interest were changes in prevalence of any CP and severity of CP over time and associations between CP and other neurodevelopmental outcomes, functional impairment, and medical comorbidities. Adjusted logistic, linear, multinomial logistic, and robust Poisson regression evaluated the relationships between child characteristics, CP severity, and outcomes. RESULTS: Among 6927 surviving children with complete follow-up data, 3717 (53.7%) had normal neurologic examinations, 1303 (18.8%) had CP, and the remainder had abnormal neurologic examinations not classified as CP. Adjusted rates of any CP increased each year of the study period (aOR 1.11 per year, 95% CI 1.08-1.14). Cognitive development was significantly associated with severity of CP. Children with CP were more likely to have multiple medical comorbidities, neurosensory problems, and poor growth at follow-up. CONCLUSIONS: The rate of CP among surviving children who were born extremely preterm increased from 2008 through 2019. At 18 to 26 months of corrected age, neurodevelopmental and medical comorbidities are strongly associated with all severity levels of CP.

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OBJECTIVE: To characterize the relationships between social determinants of health (SDOH) and outcomes for children born extremely preterm. STUDY DESIGN: This is a cohort study of infants born at 22-26 weeks of gestation in National Institute of Child Health and Human Development Neonatal Research Network centers (2006-2017) who survived to discharge. Infants were classified by 3 maternal SDOH: education, insurance, and race. Outcomes included postmenstrual age (PMA) at discharge, readmission, neurodevelopmental impairment (NDI), and death postdischarge. Regression analyses adjusted for center, perinatal characteristics, neonatal morbidity, ethnicity, and 2 SDOH (eg, group comparisons by education adjusted for insurance and race). RESULTS: Of 7438 children, 5442 (73%) had at least 1 risk-associated SDOH. PMA at discharge was older (adjusted mean difference 0.37 weeks, 95% CL 0.06, 0.68) and readmission more likely (aOR 1.27, 95% CL 1.12, 1.43) for infants whose mothers had public/no insurance vs private. Neither PMA at discharge nor readmission varied by education or race. NDI was twice as likely (aOR 2.36, 95% CL 1.86, 3.00) and death 5 times as likely (aOR 5.22, 95% CL 2.54, 10.73) for infants with 3 risk-associated SDOH compared with those with none. CONCLUSIONS: Children born to mothers with public/no insurance were older at discharge and more likely to be readmitted than those born to privately insured mothers. NDI and death postdischarge were more common among children exposed to multiple risk-associated SDOH at birth compared with those not exposed. Addressing disparities due to maternal education, insurance coverage, and systemic racism are potential intervention targets to improve outcomes for children born preterm.

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OBJECTIVE: To determine if preterm infants with surgical necrotizing enterocolitis (sNEC) or spontaneous intestinal perforation (SIP) with short bowel syndrome (SBS) have worse neurodevelopmental and growth outcomes than those with sNEC/SIP without SBS, and those with no necrotizing enterocolitis, SIP, or SBS. STUDY DESIGN: We undertook a retrospective analysis of prospectively collected data from infants born between 22 and 26 weeks of gestation in the National Institute of Child Health and Human Development Neonatal Research Network centers from January 1, 2008, to December 31, 2016. Survivors were assessed at 18-26 months corrected age by standardized neurologic examination and Bayley Scales of Infant and Toddler Development, Third Edition. The primary outcome was moderate-severe neurodevelopmental impairment. Growth was assessed using World Health Organization z-score standards. Adjusted relative risks were estimated using modified Poisson regression models. RESULTS: Mortality was 32%, 45%, and 21% in the 3 groups, respectively. Eighty-nine percent of survivors were seen at 18-26 months corrected age. Moderate-severe neurodevelopmental impairment was present in 77% of children with SBS compared with 62% with sNEC/SIP without SBS (adjusted relative risk, 1.22; 95% CI, 1.02-1.45; P = .03) and 44% with no necrotizing enterocolitis, SIP, or SBS (adjusted relative risk, 1.60; 95% CI, 1.37-1.88; P < .001). Children with SBS had lowcognitive, language, and motor scores than children with sNEC/SIP without SBS. At follow-up, length and head circumference z-scores remained more than 1 SD below the mean for children with SBS. CONCLUSIONS: Preterm infants with sNEC/SIP and SBS had increased risk of adverse neurodevelopmental outcomes at 18-26 months corrected age and impaired growth compared with peers with sNEC/SIP without SBS or without any of these conditions.

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OBJECTIVES: To determine associations between hand function at age 18-22 months (early) and scores on the Movement Assessment Battery for Children, 2nd edition (MABC) at 6-7 years of age (school age) in extremely preterm children. STUDY DESIGN: Prospective multicenter cohort of 313 extremely preterm children with early hand function assessment and school-age MABC testing. Early hand function was compared with "definite deficits" (MABC <5th percentile) and MABC standard scores. Early hand function was categorized as "no deficit" vs "any deficit." Mixed-effects regression models were used to evaluate the association of early hand function with MABC deficits, controlling for multiple demographic, neonatal, and childhood factors. RESULTS: Children with early hand function deficits were more likely to have definite school-age deficits in all MABC subtests (Manual Dexterity, Aiming and Catching, and Balance) and to have received physical or occupational therapy (45% vs 26%; P < .001). Children with early hand function deficits had lower Manual Dexterity (P = .006), Balance (P = .035), and Total Test (P = .039) scores. Controlling for confounders, children with early hand function deficits had higher odds of definite school-age deficits in Manual Dexterity (aOR, 2.78; 95% CI, 1.36-5.68; P = .005) and lower Manual Dexterity (P = .031) and Balance (P = .027) scores. When excluding children with cerebral palsy and those with an IQ <70, hand function deficits remained significantly associated with manual dexterity. CONCLUSION: Hand function deficits at age 18-22 months are associated with manual dexterity deficits and motor difficulties at school age, independent of perinatal-neonatal factors and the use of occupational or physical therapy. This has significant implications for school success, intervention, and rehabilitative therapy development.

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OBJECTIVE: To characterize behavior of 2-year-old children based on the severity of bronchopulmonary dysplasia (BPD). STUDY DESIGN: We studied children born at 22-26 weeks of gestation and assessed at 22-26 months of corrected age with the Child Behavior Checklist (CBCL). BPD was classified by the level of respiratory support at 36 weeks of postmenstrual age. CBCL syndrome scales were the primary outcomes. The relationship between BPD grade and behavior was evaluated, adjusting for perinatal confounders. Mediation analysis was performed to evaluate whether cognitive, language, or motor skills mediated the effect of BPD grade on behavior. RESULTS: Of 2310 children, 1208 (52%) had no BPD, 806 (35%) had grade 1 BPD, 177 (8%) had grade 2 BPD, and 119 (5%) had grade 3 BPD. Withdrawn behavior (P < .001) and pervasive developmental problems (P < .001) increased with worsening BPD grade. Sleep problems (P = .008) and aggressive behavior (P = .023) decreased with worsening BPD grade. Children with grade 3 BPD scored 2 points worse for withdrawn behavior and pervasive developmental problems and 2 points better for externalizing problems, sleep problems, and aggressive behavior than children without BPD. Cognitive, language, and motor skills mediated the effect of BPD grade on the attention problems, emotionally reactive, somatic complaints, and withdrawn CBCL syndrome scales (P values < .05). CONCLUSIONS: BPD grade was associated with increased risk of withdrawn behavior and pervasive developmental problems but with decreased risk of sleep problems and aggressive behavior. The relationship between BPD and behavior is complex. Cognitive, language, and motor skills mediate the effects of BPD grade on some problem behaviors.

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OBJECTIVE: To investigate associations in toddlers born extremely preterm (<28 weeks) between neonatal neuroimaging and 18- to 22-month developmental and behavioral outcomes. STUDY DESIGN: Cohort analysis from the Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network Surfactant Positive Airway Pressure and Pulse Oximetry Trial Neuroimaging and Neurodevelopmental Outcomes Study of infants born extremely preterm. Subjects underwent cranial ultrasonography and near-term magnetic resonance imaging (MRI). At 18-22 months of corrected age, the assessment included the Brief Infant Toddler Social Emotional Assessment (BITSEA) Problem and Competence Scale scores and the Bayley Scales of Infant Development, Third Edition (Bayley-III). The BITSEA Problem Scale assesses dysregulation; the Competence Scale assesses social-emotional competence. We examined associations of Problem and Competence scores and positive screen rates with cranial ultrasonography and near-term MRI. Mean BITSEA and Bayley-III scores were compared using ANOVA and positive screen rates with the χ2 test. We computed correlations between BITSEA and Bayley-III scores. RESULTS: Of the 397 children, positive BITSEA screens were found in 34% for the Problem score and 26% for the Competence score. Presence of lesions on near-term MRI that included cerebellar lesions were significantly associated with lower BITSEA Competence but not with Problem scores; Competence scores were inversely related to the presence/significance of lesions. Positive screens on Competence scores and on both Competence and Problem scores were significantly associated with Bayley-III cognitive and language scores <85 (P < .001). CONCLUSIONS: Social-emotional competence contributes to deficits in cognitive and language development. Presence of injury on near-term MRI that includes cerebellar lesions is associated with later social-emotional competence and may be a useful predictor to guide early assessment and intervention. TRIAL REGISTRATION: ClinicalTrials.gov: NCT00063063 and NCT00233324.

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OBJECTIVE: To determine whether use of digital-based screening is a feasible approach to monitoring child development, it is necessary to assess young children's abilities to interface with touch screen technology. The primary objectives of this exploratory feasibility study with a randomized experimental design were to determine (1) whether young children respond differently to developmental tasks on paper versus tablet device and (2) whether responses to items presented digitally differed according to hours of weekly exposure to touch screen technology in the home. METHODS: Eighty children attending 18-, 24-, 36-, or 48-month pediatrician well-child checks were randomly assigned to complete a series of 70 examiner-facilitated, developmental tasks across 7 domains (receptive language, expressive language, early literacy, early numeracy, social emotional, cognition, and fine motor) presented either digitally or on paper. Parents provided information about use of technology in the home. A series of t tests assessed for main effects of presentation modality (digital vs paper) on each of the domains. RESULTS: Raw scores across the 7 domains did not differ by presentation modality. Hours of technology use per week was not related to raw scores among children in the digital condition. CONCLUSION: Young children do not respond differentially to items when presented in a digital format in comparison to a paper-based format. Use of manipulatives for assessing developmental skills may be needed for children 2 years and younger, as they displayed a limited range of responses to items in both conditions at these age groups.

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OBJECTIVE: To evaluate the relationship of race/ethnicity to Cognitive and Language scores on the Bayley Scales of Infant and Toddler Development, Third Edition in extremely preterm toddlers (<28 + 0 weeks' estimated gestational age). STUDY DESIGN: This cohort study included extremely preterm toddlers seen at Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network centers evaluated at 18-22 months adjusted age from 3 race/ethnic groups (white, black, and Hispanic white). Multivariate regression modeling was used to identify race/ethnic differences, after adjusting for medical and psychosocial factors. RESULTS: The study population comprised 369 whites, 352 blacks, and 144 Hispanic whites. Cognitive scores differed among the 3 groups on unadjusted analysis (P ≤ .001), but not after adjusting for medical and psychosocial factors (P = .13). Language scores differed on adjusted and unadjusted analyses. Whites scored higher than blacks and Hispanic whites, and blacks scored higher than Hispanic whites. CONCLUSIONS: A combination of medical variables and primary caretaker education accounted for differences in Bayley Scales of Infant and Toddler Development, Third Edition Cognitive scores among the 3 groups. Black and Hispanic white toddlers had lower Language scores than whites, even after adjustment. Early intervention should be targeted to these identified risk factors. Assessment of early language development in minority children may be warranted.

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