Physiotherapy - Theses
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ItemDevelopmental outcomes and rates of early intervention at two years in infants born extremely preterm or extremely low birth weight( 2013)This thesis investigated the rates of developmental delay, neurosensory disability and early intervention at two years in a cohort of extremely preterm and/or extremely low birthweight (EP/ELBW) infants. These infants are at higher risk of impairments such as cerebral palsy (CP) or delayed development than term born infants, thus rates of impairment are a key outcome indicator. Timely access to early intervention (EI) services for EP/ELBW children with delays is recognised as important yet little is known about appropriate access to EI in Victoria, Australia. Follow-up of EP/ELBW children at two years provides a snapshot of early development and access to EI services. A systematic review and critical evaluation of the literature reporting two-year neurodevelopmental outcomes for EP/ELBW infants was performed. Rates of developmental delay and neurosensory impairments were identified in infant cohorts from the post surfactant era. Rates of CP ranged from 5% to 76% with most studies reporting rates between 10% and 20%. Most studies used the Bayley assessment to report neurodevelopmental outcome. The most prevalent developmental impairment was cognitive delay or motor delay without CP with the majority of studies reporting rates in the 15% to 40% range. Rates of delay were highest in studies from the USA compared to Australia, Europe and Asia. Methodological variability limited direct comparisons between studies and meta-analysis was not considered appropriate. A retrospective cohort study of EP/ELBW infants from the Royal Women’s Hospital (RWH) at two years corrected age was performed. Developmental outcomes of 109 children were assessed using the Bayley-III assessment tool with children classified as no delay (≥ -1 SD) mildly (<-1 to -2 SD), moderately (<-2 to -3SD) or severely delayed (<-3SD). The follow-up rate was 50% (n=109) of survivors to discharge. With reference to Bayley-III test norms, cognitive delay occurred in 18% (n=19), language delay in 29% (n=29) and motor delay in 19% (n=19) of children. A control group assessed with the Bayley-III by the Victorian Infant Collaborative Study group (VICS) provided an additional representative group against which to reference the outcomes. The VICS control group mean values were 108.9 (14.4) for cognitive, 108.3 (14.8) for language and 118.4 (16.7) for motor development. The rates of delay increased significantly for most categories when referenced to the VICS norms with the concurrent comparator group identified as important in accurately determining rates of delay. Neurosensory assessment identified a 7% rate of CP and there were no children with blindness or deafness. A retrospective audit was performed from a subcohort of this RWH EP/ELBW cohort, comprising 80 children with data reporting receipt of EI in the first two years. The rate of receipt of EI during the first two years was 68% (n=54). Birthweight significantly predicted the receipt of EI (OR 0.79; 95%CI 0.63-1.00, p=0.045). Children with moderate to severe delay were more likely to be receiving EI than those with no delay (OR 4.20; 95%CI 1.41-12.52; p=0.01) and all children with CP were receiving EI at two years. There was an unmet need for EI with at least 20% of children with moderate to severe delay and 35% with mild delay not receiving EI. There were also a large proportion (60.5%) of children with no delay at two years who received EI. A questionnaire used to capture EI services information identified that over 75% of families utilised two or more therapy disciplines in the first two years. Waiting times were reported as an area of concern despite overall satisfaction with EI services. This thesis identified rates of neurodevelopmental impairment and receipt of EI for a cohort of EP/ELBW children from the RWH. Whilst follow-up rates were low, this study identified rates of delay and disability comparable to cohorts from Australia, Europe and Asia. The rates of EI utilisation were high, however the targeting of EI to children with delays was variable. The goal for EP/ELBW children is to provide timely and targeted intervention and early developmental surveillance is needed to achieve this. Areas for future research have been identified for children born EP/ELBW to inform clinical decision-making and assist in the strategic planning for regional services.