Акушер-гинеколог и неонатолог - вредные профессии в контексте РФ стартерпак



Оно же разжовано на русском http://neuronovosti.ru/lowerthan40week/

И это лишь малая часть от неврологии, не говоря о других дисциплинах.

Most neurodevelopmental outcome studies have focused on the highestrisk
preterm infants—either VLBW (<1,500 g) or very premature (VP) born
before 32 weeks of gestation or extremely low birth weight (ELBW, <1,000
g) or EP (<26 to 28 weeks of gestation). Adverse outcomes increase
proportionately with increasing immaturity with the poorest outcomes in
the EP and ELBW group. However, more than 75 percent of all preterm
infants are moderate or late preterm, born at 32 to 36 weeks of gestation.
Recently more attention has been paid to neurodevelopmental outcomes of
these larger, more mature preterm groups. As expected their risk of adverse
cognitive and behavioral outcomes, while much lower than that of more
immature preterms, is significantly higher than that of term infants and
because of their greater numbers, contributes disproportionately to the
burden of neurodevelopmental problems associated with preterm birth.
The best outcome studies are prospective, and comprised of large,
population or geographically based cohorts with longitudinal follow-up
from infancy through adulthood. Comparison of outcomes with normal
birth weight (NBW), term-born control children is critical. Most such
studies have been performed in Australia, Canada, Scandinavia, and Great
Britain where children can be tracked easily within the health care system
over long periods of time. However, reports from single centers and smaller
samples are remarkably congruent with the results from larger,
longitudinally followed cohorts. Whether there will be substantive
differences in outcomes based on birth before and after the introduction of
antenatal steroids and surfactant in the early 1990s remains to be seen. The
current late adolescent and adult outcome studies are all derived from the
earlier time period. Thus far, outcomes during infancy and childhood are
quite similar. A myriad of variables have been associated with adverse
neurodevelopmental and psychiatric outcomes. Many of these factors are
also associated with preterm birth. A unifying, common path may be
antenatal, intrapartum, or postnatal hypoxia and/or ischemia or
inflammation, which in turn results in brain, especially white matter, injury
in this physiologically vulnerable group.
The emotional effect of preterm birth, especially extremely preterm
birth, on sibling and parental behavior and emotional well-being may be
profound and pervasive, including PTSD, anxiety, depression, and divorce.
The most immature preterm infants are critically ill for many weeks with
multiple ups and downs involving difficult decisions by both the family and
the medical team. Extremely preterm children are often survivors of
multiple gestation, adding the burden of grieving a fetal or neonatal loss to
the family dynamic. Maternal depression increases the risk of preterm
delivery and is associated with internalizing behavior, anxiety, depression,
and low social competence in their offspring.
Despite the physical, emotional, behavioral, and cognitive adversities
facing many children and adults born prematurely, the majority self-report
a satisfactory quality of life. Often self-perception is more positive than
parent or teacher report particularly with regard to ADHD and depression.
Whether this is lack of self-awareness or reflects resilient coping
mechanisms is not clear. The majority of preterm adults compensate for
their difficulties and go on to lead full, productive lives.

VLBW or VP children have moderate to severe cognitive deficits with a
decrement of 0.8 SD on measures of IQ. The magnitude of cognitive
deficits is inversely correlated with gestational age. Moderate and late
preterm children born at ≥32 weeks of gestation score an average of 8
points lower, VP children born from 28 to 31 weeks of gestation score 11
points lower, and EP children born at <28 weeks of gestation score 14
points lower—a decrease of approximately 1.5 IQ points/week if born
before 33 weeks of gestation. EP/ELBW are 2 to 3 times more likely to have
impaired attention than term controls. Deficits include delays in selective,
sustained, encoding, divided, and shifting attention with decrements in
standardized scores increasing to 0.6 SD at <26 weeks of gestation. Their
processing speed, the time required to interpret and respond to incoming
stimuli, is also slower. Compared to term controls VP/VLBW children are 2
to 3.5 times more likely to have deficits in all aspects of memory including
short-term working memory, long-term episodic (events) memory, and
semantic (facts) memory. Impaired visual acuity and visual/perceptual
processing problems are common. It is therefore not surprising that
executive function is also often impaired. These deficits do not appear to
improve over time. Some, such as attention-related difficulties and
executive function, tend to worsen as intellectual challenges become
increasingly complex.
Academic performance, especially for the EP/ELBW child is moderately
to severely affected, and due in part to specific learning disabilities in
mathematics, reading, and spelling, often being worse than expected for a
given IQ. In one study, compared with term controls, children born at <26
weeks of gestation were more likely to have impairment at 11 years of age in
reading (52 vs. 11 percent) and mathematics (70 vs. 14 percent). In another
study 65 percent of ELBW children at 8 to 9 years of age had at least one
learning disability compared to 13 percent of those born at term. Although
many VP/VLBW children may require some special educational resources
at some point in their education, most VP/VLBW children are in
mainstream classes and graduate from high school; many attend college
and pursue postgraduate degrees.

Behavior problems are three to eight times more common in the preterm
child compared to their term counterparts. Preterm children are more
likely to have internalizing and less likely to have externalizing problems.
The preterm behavioral phenotype has been described as being inattentive,
anxious, and socially withdrawn. Psychiatric disorders are often comorbid
with other preterm-related cognitive, motor, and neurosensory
impairments making diagnosis and treatment more difficult. Being born
preterm substantially increases the risk of psychopathology especially
anxiety, depression, ADHD, and autism. As with other outcomes, the risk
increases with decreasing gestational age, rising sharply for those born at
less than 31 weeks of gestation. Very preterm children are two to three
times more likely than moderate to late preterm children to have
nonaffective psychosis, depressive disorder, and bipolar disorder. The risks
of autism spectrum disorder (ASD), emotional, and behavior problems are
each ten times higher if born at 23 to 27 weeks compared to ≥37 weeks of
gestation. Many children have some features of ADHD or ASD but not
enough to meet the full diagnostic criteria. For instance, although 25
percent of low birth weight (LBW) children are reported by parents to have
attention problems on the Child Behavior Checklist (CBCL), only onequarter
of these meet diagnostic criteria for ADHD.
In mid-childhood, 23 percent of EP children were reported to have a
psychiatric diagnosis compared to 9 percent of term children (OR 3.2). In
this same study, compared to term children, EP children were more likely
to have ADHD (12 percent vs. 3 percent), emotional disorders (9 percent
vs. 2 percent), and ASD (8 percent vs. 0 percent). In a meta-analysis
including five studies of LBW, preterm adolescents, one in four had a
psychiatric diagnosis (OR 3.66). In another study of VLBW children midadolescence,
11 percent had cerebral palsy and 18 percent had moderate
mental retardation, 46 percent had emotional or behavioral problems and
25 percent had psychiatric symptoms fulfilling at least 75 percent of
diagnostic criteria. For moderately preterm, young adults, the prevalence of
a psychiatric disorder at 19 years of age was higher than their full-term
counterparts (30 percent vs. 19 percent). At 19 years of age, the primary
disorders were mood disorder, ADHD, and antisocial personality with
males and females being equally affected. Interestingly, the risk of having a
psychiatric problem increased from 11 to 19 years. More than 50 percent of
those with a disorder at 19 years had not had a psychiatric diagnosis when
seen at 11 years of age. From a National Registry database, the risk of
hospitalization for any psychiatric diagnosis doubles below 33 weeks of
Studies of preterm young adults have noted decreased risk-taking
behavior, delinquency, and incarceration as compared with their peers. The
reasons for this are unclear but may reflect lack of interest or opportunity,
decreased social interactions, or increased protection by the family.

Structural and functional MRI studies demonstrate substantial differences
in regional brain volumes and neural connectivity including smaller
hippocampal, thalamic, caudate, corpus callosum, and cerebellar volumes
as well as thinner cortices found in infants, children, and adolescents born
preterm. Disorganization of tracts in the internal capsule and posterior
corpus callosum indicates widespread alterations in neural connectivity.
Functional MRI and DTI demonstrate that preterm children utilize novel
neural pathways to complete tasks suggesting the development of
alternative networks to compensate for abnormal brain development or

In a study from the United States, the attributable risk of LBW(<2,500 g)
for depression in female adolescents based on screening questionnaire
followed by psychiatric assessment was 18 to 24 percent of LBW females
versus 3 percent of NBW females being depressed. LBW adolescent females
were also found to be less resilient than their NBW peers. Fewer risk
factors were associated with depression in LBW females: for one risk factor
20percent of LBW versus 5 percent of NBW and for two risk factors 85
percent of LBW versus 20 percent of NBW females were diagnosed with
depression. In this study and others the risk of depression was not
increased in preterm male adolescents. Much lower rates of adolescent
depression were also found in a population-based cohort from Australia
where 15 percent of preterm LBW adolescent girls and 1 percent of preterm
LBW adolescent males had stable depression in comparison to 2 percent of
term females and 0.25 percent of term male adolescents. The OR for LBW
adolescents for developing a stable depressive disorder was 11.6 after
adjustment for background confounders. Moderate to late preterm young
adults born at 32 to 36 weeks of gestation are 2.7 times more likely and
very preterm young adults born before 32 weeks of gestation are 7.4 times
more likely to develop bipolar disorder.
The prevalence of ADHD is two to four times greater in preterm children
and occurs more often in the most premature children. The majority of
preterm children have inattentive ADHD subtype rather than combined or
hyperactive/impulsive subtypes. In one large population-based study, EP
children had a high rate of generalized attention impairment at 11 years of
age—77 percent were impaired in at least one area of attention and 50
percent were impaired in two areas. In the same cohort seen at 17 years of
age, 18 percent had clinical ADHD compared to 7 percent of the term
adolescents. Unlike in term children where there is a male predominance,
preterm girls and boys are equally affected. Neonatal factors are weak
predictors of attention impairment and ADHD. Poor intrauterine growth
may contribute to the risk of hyperactivity. In a large twin study, the lower
birth weight twin scored higher on a hyperactivity scale. In preterm
children with ADHD, neuroanatomical changes are present on MRI. There
are structural and functional abnormalities in specific structures and in the
fronto-striatal-cerebellar circuitry with evidence of hyperactivation in some
areas and decreased activation in others. Numerous antenatal,
intrapartum, and postnatal factors have been associated with ADHD.
The prevalence of autism in preterm children is two to three times the
prevalence in overall population. There is a gradual increase in risk of ASD
associated with decreased length of gestation with the most immature and
the smallest at highest risk of ASD. Clinically, preterm and LBW children
have predominately social and communication problems, with less
stereotypic, repetitive movements and more motor and cognitive delays.
A high proportion (21 to 41 percent) of VP children fail the Modified
Checklist for Autism in Toddlers (MCHAT) screener at 18 to 24 months of
age. However, these results are strongly influenced by concomitant
cognitive, motor, and neurosensory impairments. The percentage of
positive screens is much lower following confirmatory interviews. In later
childhood and adolescence the prevalence of ASD is 5 percent in LBW
children and up to 8 percent in ELBW or EP children. Although the overall
prevalence of autism is four times higher in males, the risk is higher for
preterm girls born at less than 33 weeks of gestation. Preterm girls are also
more likely to have co-morbid conditions.
Many variables associated with ASD occur more frequently with
preterm delivery including advanced maternal age, maternal hypertension,
twins, assisted reproductive technology, antenatal antidepressant
medication, gestational diabetes, antenatal infection, birth order, and
antenatal bleeding, intrauterine growth restriction/small for gestational
age, fetal distress, abnormal presentation (breech), induced labor, summer
delivery, umbilical cord complications, low Apgar score, needs for neonatal
intensive care, hypoxia, jaundice, respiratory distress, feeding difficulties,
meconium aspiration, anemia, hemolytic disease of the newborn,
congenital malformation, and lack of maternal breast milk feeding. Most of
these variables are either primarily or secondarily associated with
hypoxic/ischemic, inflammatory or toxic brain injury. Both genetic and
environmental components of autism have been demonstrated in twin
studies which have high rates of concordance in identical but not dizygotic
twins. When identical twins are discordant for ASD, the smaller twin,
presumably with the less optimal intrauterine environment, is more likely
to be affected. Autism is associated with cranial imaging abnormalities
including ventricular dilatation, intracranial hemorrhage, parenchymal
white matter volume loss, isolated cerebellar injury, and hypoplasia of the
cerebellar vermis.

Given the low prevalence of nonaffective psychosis, little information is
available. The few studies from mental health or large birth registries
associate preterm birth, hypoxia and related obstetrical complications (e.g.,
perinatal asphyxia), fetal undergrowth, and preeclampsia with
schizophrenia. Moderate to late preterm young adults born at 32 to 36
weeks of gestation are 1.6 times more likely and very preterm young adults
born before 32 weeks of gestation are 2.5 times more likely to develop
nonaffective psychosis. Brain abnormalities associated with schizophrenia
include cerebellar hypoplasia, severe IVH, and ventricular dilatation.
In conclusion, psychiatric conditions including depression, anxiety,
autism, ADHD, and nonaffective psychosis are all more prevalent in
children, adolescents, and adults born prematurely. The risk increases
steadily with increasing prematurity, such that those born at less than 28
weeks of gestation are at highest risk. Abnormalities in brain structure and
function incurred as a result of preterm birth have been implicated in
adverse neurodevelopmental and psychiatric outcomes.

Данный выше текст из Kaplan and Sadock’s: Comprehensive Textbook of Psychiatry10th ed 2017

И т.д.