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Background: Improved survival in extremely low birth weight infants (ELBWI) in Sub-Saharan Africa has raised the question whether these survivors have an increased chance of adverse neurodevelopmental outcomes. Objectives: To describe neurodevelopmental outcomes of ELBWI in a neonatal unit in South Africa. Methods: This was a prospective follow-up study. All ELBWI who survived to discharge between 1 July 2013 and 31 December 2017 were invited to attend the clinic. Bayley Scales of Infant and Toddler Development (version III) were conducted at 9 to 12 months and 18 to 24 months. Results: There were 723 ELBWI admissions during the study period, 292 (40.4%) survived to hospital discharge and 85/292 (29.1%) attended the neonatal follow up clinic. The mean birth weight was 857.7 g (95% CI: 838.2–877.2) and the mean gestational age was 27.5 weeks (95% CI 27.1–27.9). None of the infants had any major complication of prematurity. A total of 76/85 (89.4%) of the infants had a Bayley-III assessment at a mean corrected age of 17.21 months (95% CI: 16.2–18.3). The mean composite scores for cognition were 98.4 (95% CI 95.1–101.7), language 89.9 (95% CI 87.3–92.5) and motor 97.6 (95% CI 94.5–100.6). All mean scores fell within the normal range, The study found 28 (36.8%) infants to be “at risk” for neurodevelopmental delay. Conclusion: Our study demonstrates good neurodevelopmental outcome in a small group of surviving ELBWI, but these results must be interpreted in the context of the high mortality in this group of infants.
This was a prospective follow-up study of ELBWI born between 1 July 2013 and 31 December 2017. The study was conducted at the neonatal unit of a tertiary hospital in Johannesburg, South Africa. Charlotte Maxeke Johannesburg Academic Hospital (CMJAH) is a public sector hospital that serves a low socioeconomic community that does not have access to private health insurance All ELBWI who survived to hospital discharge were invited to enrol. Enrolment was done at the first clinic visit. The ELBWI study group were seen at the study clinic every 3 months until the corrected age of 24 months. To improve rates of follow-up, text messages were sent to parents of enrolled participants as reminders of follow-up appointments. Transport costs were refunded and defaulting patients were traced and rebooked where possible. Appropriately trained paediatricians and physiotherapist performed the developmental assessments using the Bayley Scales of Infant and Toddler Development, version III (Bayley-III) (11). The Bayley III was validated in the same setting (14). The first Bayley-III assessment was conducted between 9 and 12 months; the second between 18 and 24 months (if patient still attended the follow up clinic). The Bayley-III assessment would be done at the next visit if a child defaulted a study clinic visit. The Bayley-III scores were calculated using the age corrected for prematurity. The gestational age was assessed by maternal menstrual history and clinical assessment using the Ballard score (11). The Cronbach’s alpha interclass correlation between different observers for neurodevelopment assessment was 0.89 (14). Infants with congenital abnormalities that were likely to affect neurodevelopment, for example Trisomy 21, were subsequently excluded from the study. Developmental delay was classified “at risk” if a composite Bayley-III score was below 85 on any of the cognitive, language or motor sub-scales and as “delayed” if a composite Bayley-III score was below 70 on any of the sub-scales (14). Cerebral palsy was diagnosed if there was a delay in motor milestones together with abnormal movement and/or posture (14). Hearing and vision were indirectly assessed as part of the Bayley-III language and motor assessment. Where developmental problems were identified, the child was referred for appropriate intervention by the allied medicine team (physiotherapy, occupational therapy and speech therapy). Data were entered and managed using Research Electronic Data Capture (REDCap™) software, hosted by the University of Witwatersrand (15). Maternal variables included demographics, antenatal care (ANC), obstetric history, place and mode of delivery. Neonatal variables included gestational age, birth weight, sex, duration of ventilation and stay, neonatal morbidity, late sepsis and outcome. The data were exported into SPSS version 23 (IBM, USA) for statistical analysis. The latest Bayley-III score for each child was used for analysis. The composite cognitive, language and motor scores were used as outcome variables. If continuous variables were normally distributed, the data was described using mean and 95% confidence intervals (95% CI). Skewed data was described using median and interquartile range (IQR). Categorical variables were described using frequency and percentages. Survivors and non-survivors were compared–continuous variables were compared using unpaired t test or Mann Whitney U depending on the data distribution. Categorical variables were compared using Chi Square. Only valid cases were analysed for each variable (i.e., missing data was excluded). Written informed consent was obtained from the parents of each participant prior to study enrolment. The Human Research Ethics Committee of the University of the Witwatersrand, Johannesburg, approved the study (reference numbers M120623 & M170702).
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