Desenvolvimento psicomotor de crianças pré-termo em idade pré-escolar: resultados do primeiro estudo epidemiológico de base hospitalar no interior norte de Portugal
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2016
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A prematuridade representa um fator de risco para o desenvolvimento
psicomotor (DPM) de incidência crescente, estando ainda por caracterizar a sua
epidemiologia no interior norte de Portugal. Este estudo teve como objetivo avaliar, em
idade pré-escolar, a incidência de atraso do DPM de crianças pré-termo, particularmente
pré-termos tardio, e aferir a perceção dos pais sobre o DPM dos seus filhos prematuros e o
impacto da prematuridade neste contexto.
MATERIAIS E MÉTODOS. Concebeu-se um estudo do tipo coorte, para o qual se recrutaram
todas as crianças internadas numa unidade de referência em neonatologia no interior norte
de Portugal (UCERN), em 2009. Incluíram-se os dados biológicos, as variáveis obstétricas
e os indicadores do estado de saúde geral do recém-nascido. As crianças foram
reavaliadas aos 36 meses, reavaliados os parâmetros antropométricos, averiguadas as
aquisições e recolhidos os elementos sociodemográficos e familiares. Procedeu-se à
avaliação do seu DPM pelas Escalas de Desenvolvimento Mental de Griffiths, Extensão
Revista (2006), dos 2 aos 8 anos (EDMG), definindo-se atraso do DPM pela obtenção de
uma pontuação geral padronizada (nota/estatística Z) inferior a 2 desvio-padrão da média
(Z <-1.2), severo Z < -2 e limítrofe/borderline -1.9 ≤ Z ≤ -1.3. Solicitou-se aos pais que
qualificassem o DPM dos seus filhos de “muito fraco a muito bom”. As respostas foram
comparadas como as pontuações das EDMG. A eficiência preditiva da perceção parental
do DPM foi aferida através do cálculo da área sob a curva (AUC), Inquiriram-se os pais
sobre a influência da prematuridade no DPM dos seus filhos e na generalidade.
RESULTADOS. Das 337 crianças nascidas pré-termo (18.8% do total dos 1788 nados
vivos), incluíram-se as 102 que estiveram internadas na UCERN. Destas, 77 concluíram a
avaliação, constituindo a coorte (23%). A maioria nasceu de parto pré-termo tardio (n=56,
72.7%), nenhuma de parto pré-termo extremo. O parto ocorreu por cesariana em 55.8%,
72, 92.5% nasceram com peso adequado à idade gestacional, 4 necessitaram de
ventilação, 80% iniciou aleitamento materno (média 3º dia). A incidência de gemelaridade
foi 27.3% (n=21). Não houve mortalidade. A idade média à avaliação foi 38.8 meses (33 - 47). Nenhuma criança fora referenciada como portadora de relevante morbilidade cognitiva
ou motora. A maioria apresentava valores antropométricos e aquisições ocorridas em
idade expectável. A incidência de atraso do DPM foi 22% (n=17), 14.3% (n=11) severo e
7.8% (n=6) limítrofe/borderline. No grupo pré-termo tardio foi 19.6% (n=11), 12.5% severo
(n=7) e 7.1% limítrofe/borderline (n=4). Os domínios com maior frequência com
pontuações deficitárias foram aaudição e linguagem (severo n=16, 20.8%;
limítrofe/borderline n=12, 15.6%), locomoção (severo n=12, 15.6%;
limítrofe/borderline n=14, 18.2%) e coordenação olho-mão (severo n=11, 14.3%;
limítrofe/borderline n=12, 15.6%). Apenas 1 dos pais qualificou o DPM do filhos como
“fraco”, nenhum com “muito fraco”, 11.7% (n=9) respondeu “satisfatório”, 63.3% (n=49)
“bom” e 23.4% (n=18) “Muito bom”. A AUC calculada para aferir a perceção parental sobre
o DPM foi 0.68 (IC95% 0.54 a 0.82). Menos de metade dos pais (46.8%) afirmou que a
prematuridade influencia o DPM infantil e apenas 35% reconheceram tal nos seus filhos.
Em 90.7% dos casos o agregado familiar incluía 3 a 5 conviventes. Um terço dos pais e
dois terços das mães tinham a escolaridade obrigatória. A escolaridade dos progenitores
provou influenciar o DPM (proporção de mães com escolaridade ≥ 12 anos foi 5.9% no
grupo com atraso vs 35%, p=0.007; proporção de pais com escolaridade ≥ 12 anos foi
0.0% no grupo com atraso vs 15.0% , p=0.047) e a opinião relativamente ao risco da
prematuridade, no plano geral e individual. Em 96.1% dos casos as refeições eram feitas
em família, o que teve influência favorável no DPM (81.1% no grupo sem atraso vs 18.9,
p=0.009). A proporção em que o aleitamento materno foi iniciado precocemente foi menor
nas crianças com atraso (58.8 vs 85.0%, p=0.037). A proporção de crianças filhas de mães
multíparas foi maior no grupo com atraso (76.5% vs 46.3% p=0.037). Não se identificaram
outras diferenças significativas entre as crianças com e sem atraso.
CONCLUSÕES. A incidência de atraso do DPM em idade pré-escolar de crianças pré-termo
é significativa e pouco percetível para os pais. Confirma-se o efeito positivo da
escolaridade dos pais, do aleitamento materno precoce, da dinâmica familiar e
multiparidade no DPM de crianças pré-termo. Os pais tenderam a negligenciar a influência
adversa da prematuridade, o que se verificou estar relacionado com o seu nível de
escolaridade. Há necessidade de implementar localmente programas de vigilância precoce
do DPM no contexto da prematuridade e de sensibilizar a comunidade quanto ao seu risco no DPM infantil.
Prematurity is an independent risk factor to neurodevelopmental (ND) adverse outcomes. Preterm birth rates are increasing worldwide. Acknowledging the lack of reliable data about prematurity in our setting, we conducted this study to: understand our epidemiological profile; assess ND outcomes at preschool age; evaluate parental perception on ND outcomes and the influence of prematurity on it. METODOLOGY. It was a single-centre cohort study. All preterm admitted to a neonatal hospital care unit in the north of Portugal (UCERN) during 2009, were enrolled. Relevant biological and clinical and obstetric data were prospectively collected at birth. Children underwent evaluation at the chronological age of 36 months. Anthropometric measures were reassessed, functional, demographic and familiar parameters were gathered. ND outcome was assessed using the Griffiths Mental Development Scales (2-8 years). Neurodevelopment impairment (NDI) was defined by standardized score Z < -1.2 (severe Z < -2; borderline -1.9 ≤ Z ≤ -1.3). Parents were asked to rate their children ND from “very weak to very good”. Answers were plotted against Griffiths General Z score using receiveroperating characteristic (ROC) analysis to evaluate parent ability to predict infants ND performance. Parent’s opinion about the ND influence of prematurity, generally and in the specific case of their sons, was inquired. RESULTS. From all of 337 preterm births (18.8% out of the 1788 live births), 102 children were recruited, 77 concluded follow-up, constituting the cohort (23% of all). Most 72.7% (n=56), were late preterm, no one was born extremely preterm. Caesarean delivery occurred in 55.8%. Almost all had adequate weight to gestation age (n=72, 92.5 %). Only 4 needed ventilatory support and 80% initiated breastfeed, mean at the 3rd day of live. Multiple births rate was 27.3% (n=21). Mean age at follow-up was 38.8 months (range 33 to 47). Anthropometric measures were adequate in most; walking, language and diurnal sphincter control were developed at the expected age. No child was addressed for major neurological impairment. Mortality was null till the end of follow-up. Incident of ND impairment (NID) was 22% (n=17), 14.3% (n=11) severe and 7.8% (n=6) borderline. In late preterm the NDI incidence was 19.6% (n=11), 12.5% (n=7) severe and 7.1% (n=4) borderline. Adverse outcomes were more frequent on Griffiths subscales hearing and speech (severe n=16, 20.8%; borderline n=12, 15.6%), locomotion (severe n=12, 15.6%; borderline n=14, 18.2%) and hand coordination (severe n=11, 14.3%; borderline n=12, 15.6%). Children distribution among parent´s rates was: Very weak n=0; Weak n=1 (1.3%); Satisfactory n=9 (11.7%); Good n=49 (63.3%); Very good n=18 (23.4%). Area under the ROC curve was 0.68 (IC95% 0.54 a 0.82). Prematurity was acknowledgeable by parents as ND risk factor in 46.8%. Only 35% recognized its impact on ND of their children. Families included 3 to 5 members in 90.7% of the cases. Fifty-six infants (72.7%) attended kindergarten. One third of the fathers and two thirds of mothers achieved compulsory education level. Parental educational level was found to interfere with children ND (proportion of mothers ≥ 12 school years 5.9% in NDI group vs 35% non-NDI, p=0.007; proportion of fathers ≥ 12 school years 0,0% in NDI group vs 15,0% non-NDI, p=0.047) and with the awareness of prematurity as ND risk factor of prematurity. Children with NDI were significantly less prone to have meals in family (81.1% vs 18.9%, p=0.009). Rate of early breastfeed was significantly lower among Infants with NDI, 58.8% vs 85.0%, p=0.037. Proportion of mothers with 2 or more previous labours was higher among NDI group for children (76.5% vs 46.3% p=0.037). No other differences, regarding infants characteristic, reached statistical significance between children with or without NDI. CONCLUSION. Incidence of adverse ND outcomes in preschool age preterm children is significant. Parents might not be aware of its magnitude, which seems to be an educational bias. Early breastfeed, parent’s education, family environment and maternal obstetrics antecedent’s, appear to play a major role in the ND of preterm children. These findings advise us to early refer preterm children to ND assessment and to reinforce the concept of prematurity as a NID risk factor in our community.
Prematurity is an independent risk factor to neurodevelopmental (ND) adverse outcomes. Preterm birth rates are increasing worldwide. Acknowledging the lack of reliable data about prematurity in our setting, we conducted this study to: understand our epidemiological profile; assess ND outcomes at preschool age; evaluate parental perception on ND outcomes and the influence of prematurity on it. METODOLOGY. It was a single-centre cohort study. All preterm admitted to a neonatal hospital care unit in the north of Portugal (UCERN) during 2009, were enrolled. Relevant biological and clinical and obstetric data were prospectively collected at birth. Children underwent evaluation at the chronological age of 36 months. Anthropometric measures were reassessed, functional, demographic and familiar parameters were gathered. ND outcome was assessed using the Griffiths Mental Development Scales (2-8 years). Neurodevelopment impairment (NDI) was defined by standardized score Z < -1.2 (severe Z < -2; borderline -1.9 ≤ Z ≤ -1.3). Parents were asked to rate their children ND from “very weak to very good”. Answers were plotted against Griffiths General Z score using receiveroperating characteristic (ROC) analysis to evaluate parent ability to predict infants ND performance. Parent’s opinion about the ND influence of prematurity, generally and in the specific case of their sons, was inquired. RESULTS. From all of 337 preterm births (18.8% out of the 1788 live births), 102 children were recruited, 77 concluded follow-up, constituting the cohort (23% of all). Most 72.7% (n=56), were late preterm, no one was born extremely preterm. Caesarean delivery occurred in 55.8%. Almost all had adequate weight to gestation age (n=72, 92.5 %). Only 4 needed ventilatory support and 80% initiated breastfeed, mean at the 3rd day of live. Multiple births rate was 27.3% (n=21). Mean age at follow-up was 38.8 months (range 33 to 47). Anthropometric measures were adequate in most; walking, language and diurnal sphincter control were developed at the expected age. No child was addressed for major neurological impairment. Mortality was null till the end of follow-up. Incident of ND impairment (NID) was 22% (n=17), 14.3% (n=11) severe and 7.8% (n=6) borderline. In late preterm the NDI incidence was 19.6% (n=11), 12.5% (n=7) severe and 7.1% (n=4) borderline. Adverse outcomes were more frequent on Griffiths subscales hearing and speech (severe n=16, 20.8%; borderline n=12, 15.6%), locomotion (severe n=12, 15.6%; borderline n=14, 18.2%) and hand coordination (severe n=11, 14.3%; borderline n=12, 15.6%). Children distribution among parent´s rates was: Very weak n=0; Weak n=1 (1.3%); Satisfactory n=9 (11.7%); Good n=49 (63.3%); Very good n=18 (23.4%). Area under the ROC curve was 0.68 (IC95% 0.54 a 0.82). Prematurity was acknowledgeable by parents as ND risk factor in 46.8%. Only 35% recognized its impact on ND of their children. Families included 3 to 5 members in 90.7% of the cases. Fifty-six infants (72.7%) attended kindergarten. One third of the fathers and two thirds of mothers achieved compulsory education level. Parental educational level was found to interfere with children ND (proportion of mothers ≥ 12 school years 5.9% in NDI group vs 35% non-NDI, p=0.007; proportion of fathers ≥ 12 school years 0,0% in NDI group vs 15,0% non-NDI, p=0.047) and with the awareness of prematurity as ND risk factor of prematurity. Children with NDI were significantly less prone to have meals in family (81.1% vs 18.9%, p=0.009). Rate of early breastfeed was significantly lower among Infants with NDI, 58.8% vs 85.0%, p=0.037. Proportion of mothers with 2 or more previous labours was higher among NDI group for children (76.5% vs 46.3% p=0.037). No other differences, regarding infants characteristic, reached statistical significance between children with or without NDI. CONCLUSION. Incidence of adverse ND outcomes in preschool age preterm children is significant. Parents might not be aware of its magnitude, which seems to be an educational bias. Early breastfeed, parent’s education, family environment and maternal obstetrics antecedent’s, appear to play a major role in the ND of preterm children. These findings advise us to early refer preterm children to ND assessment and to reinforce the concept of prematurity as a NID risk factor in our community.
Descrição
Tese de Doutoramento em Ciências do Desporto
Palavras-chave
Desenvolvimento psicomotor , Neurodesenvolvimento , Pré-termo , Prematuridade