Since fetal alcohol syndrome was first reported, studies have demonstrated a range of perinatal/developmental abnormalities that fall under the umbrella term fetal alcohol spectrum disorders. Of these, low birth weight in exposed children is among the most commonly observed and widely accepted. However, in the past, assertion of an association between prenatal alcohol exposure and preterm birth was controversial. Methodological difficulties may have contributed to failure to consistently detect such a relationship. However, new evidence suggests that pregnancy drinking may be a major contributor to extreme, but not mild prematurity. Extreme prematurity is a major cause of severe perinatal morbidity and mortality. If recent findings are confirmed, it suggests that extreme prematurity might be reduced by eliminating prenatal alcohol exposure.

Background: Rates of preterm delivery, a major proximate cause of perinatal morbidity and mortality, have been increasing. Prenatal alcohol exposure has been implicated in preterm delivery, although results have been inconsistent due to inadequate control for confounding factors, insufficient power, unreliable and inaccurate assessment of both exposure and gestational age, and lack of stratification of prematurity into severity levels. The purpose of this study was to examine the relation between maternal alcohol, cocaine and cigarette use during pregnancy, and extreme and mild preterm birth. Methods: Three thousand one hundred thirty consecutive gravidas were followed prospectively for antenatal substance use and had ultrasound confirmed pregnancy dating. Results: Alcohol and cocaine, but not cigarette use, were associated with increased risk of extreme preterm delivery after control for potential confounders. For every unit increase in alcohol exposure, risk of extreme preterm delivery increased significantly [odds ratio (OR) 34.8]. Furthermore, in women aged 30+, alcohol exposure was associated with mild prematurity. Abstention from alcohol while continuing to use cocaine and tobacco was related to a decrease in extreme prematurity of 41%. Conclusions: The risk of extreme preterm delivery associated with alcohol use is substantial and similar in magnitude to other well-recognized risks. Increased accuracy in identifying exposure and the use of ultrasound to confirm gestational age dating likely contributed to the findings of the current study. These findings suggest that eliminating pregnancy alcohol use might substantially reduce the risk of preterm delivery.

The presented thesis deals with the topic of development of communication abilities in preterm infants from the perspective of special education. The thesis is for clarity divided into several parts. In the first part of the text the issue of incidence of premature births in the Czech Republic is discussed, following subsections are devoted to the definition and distribution of characteristics bonding with immaturity of child and approach selected health problems associated with postpartum adaptation and subsequent psychomotor development of child. The following chapter which analyzes the system of care for premature newborns in the Czech Republic focuses on two forms of care, acute care and followed-up. Next part has been devoted to issue of premature infants from logopedical perspective and describes the physiological process of development of communication abilities of child and based on current knowledge, especially foreign research, analyzes the peculiarities of speech development of preterm infants. The last and key part of the work, based on case studies, analyzes the specifics of development of communication abilities of four originally extremely and very preterm children of multiple pregnancies in the background of the their overall psychomotor development. KEYWORDS premature infant,...

一、研究目的 (1). 將針對世界各國相關規範下，早產兒之法律地位進行探討，以釐清現行我國規範對於早產兒法律地位所持之立場。 (2). 促進我國法界前輩更了解照顧早產兒，特別是極早期早產兒所遭遇的醫學倫理困境，能制定更清楚明確的有關極早期早產兒救治的相關法律或更貼切的法律實務判例或見解。 二、研究方法 (1). 文獻探討法，為了解分析照顧早產兒之醫學倫理困境，閱讀中外學者之研究報告、論著等文獻，加以探討。 (2). 歷史比較研究法，蒐集東西方歷史文獻嬰兒生命權利關係之演變資料加以分析；並且比較探討大陸法系及英美法系諸國對相關之早產兒生命權利相關醫學倫理規範及法律規定。 三、研究內容 (1). 早產兒倂發症、後遺症及存活率之情況 (2). 東西方嬰兒生命權利關係之演變史 (3). 照顧早產兒之醫護人員及早產兒家長的困境研究 (4). 國內生命權相關法律規定及醫療法規之分析 (5). 國內外極早期早產兒生命權相關醫學倫理規範及法律規定之分析比較 (6). 更適切之早產兒生命權利法律見解之提出 四、研究結果 經由本研究，基本上理解各國對早產兒生命的尊嚴及生命決定權的醫學倫理規範、法律規定及理論構成，同時也希望藉由此研究能讓政府、社會、法界及醫界對於早產兒生命權利及所遭遇的醫學倫理困境更加重視，我國能制定更清楚明確的有關極早期早產兒救治的相關法律或更貼切的法律實務判例或見解。 / As article 3 of the Universal Declaration of Human Rights prescribes “Everyone has the right to life, liberty and security of person.”, the right to life is the most fundamental human right. However, extremely preterm infants (20 to 23 weeks of gestation) are infants of borderline viability. They are at greater risk for mortality and severe disability. Who can surrogate to make decisions about resuscitation with intensive care or palliative care for them in terms of their best interests? It is a dilemma. There is a potential conflict between palliative care and the general medical duty to save life. It presents complex medical, legal, ethical and social issues for their parents and the health professionals. Until now, it is still out ruled legally in Taiwan. This article focuses on the right to life of extreme prematurity. We will discuss different insights about the right to life of infant from history, culture, society and religion in the world, and analyze guidelines and legal regimes of different countries. Based on that, we can get objective solutions to the right to life of extreme prematurity in Taiwan, as an aid for parents in making ethical and legally based decisions.

Made available in DSpace on 2016-06-02T19:46:30Z (GMT). No. of bitstreams: 1 6354.pdf: 1294561 bytes, checksum: 3be7fe07f80854809bf2a4239bbf19d9 (MD5) Previous issue date: 2014-02-20 / Financiadora de Estudos e Projetos / Children born premature and extreme birth weight are more likely to have cognitive, neuropathological and behavioral changes such as attention deficit hyperactivity disorder (ADHD). Early identification of ADHD is important because it is known that the effects caused by this disorder in school and personal lives may pass into adulthood, and the social and educational impact can cause those students requiring specialized educational assistance. In this sense, the present study aimed at identifying early signs suggestive of Attention Deficit Hyperactivity Disorder (ADHD) in children at 3 years of age with a history of extreme preterm birth and low birth weight. The sample comprised 29 children with a history of extreme prematurity and low birth weight with 3 years old now, enrolled in municipal schools. Participants were first characterized with the CCEB (Economic Classification Criterion Brazil) to homogenize the sample. After, were evaluated with the SDQ questionnaire version Pa 3/4 years (for the parents) and version Pr 3/4 years (for teachers). We also used the Denver II screening test in order to evaluate the overall development of these children and relate to behavioral findings. From the statistical correlation - Pearson Correlation - the data we found that there was a significant correlation between the variables IG with hyperactivity subscale, indicated by SDQ Pa (R= -,465*), correlation between IG and birth weight with the hyperactivity subscale, indicated by SDQ Pr ( R= -,528**; R= -,429*, respectivamente). All these correlations were significantly negative which confirms findings in the literature, that is, the lower gestational age and birth weight, the greater are the chances of having behavioral problems suggestive of ADHD. It was also verified that parents and teachers rated similarly children's development. It is concluded that children with a history of preterm birth and low birth weight have signs suggestive of ADHD at 3 years of age, and that the performance of screening for early detection of these signals facilitates therapeutic intervention and can thereby reduce the performance impact academic school with a history of extreme preterm birth and low birth weight. / Crianças nascidas prematuras extremas e com baixo peso, igual ou inferior a 2500g, estão mais propensas a apresentarem alterações cognitivas e neuropatológicas, bem como alterações comportamentais, tais como o Transtorno de Déficit de Atenção e Hiperatividade (TDAH). A identificação precoce do TDAH é importante, pois sabe-se que as repercussões causadas por este transtorno na vida escolar e pessoal podem repercutir até a vida adulta, e o impacto social e educacional pode fazer com que esses alunos necessitem de assistência educacional especializada. Neste sentido, o presente estudo teve por objetivo geral identificar sinais precoces sugestivos do Transtorno de Déficit de Atenção e Hiperatividade (TDAH), em crianças aos 3 anos de idade com histórico de nascimento prematuro extremo e baixo peso ao nascer. A amostra foi composta por 29 crianças com histórico de prematuridade extrema e baixo peso ao nascer com 3 anos de idade atual, matriculadas na rede municipal de ensino. Os participantes foram caracterizados primeiramente com o CCEB (Critério de Classificação Econômica Brasil), a fim de homogeneizar a amostra. Após foram avaliado com o questionário SDQ versão Pa3/4anos (destinado a pais) e versão Pr3/4 anos (destinado a professores). Foi utilizado também, o teste de triagem Denver II, no intuito de avaliar o desenvolvimento global destas crianças e relacionar com os achados comportamentais. A partir da análise estatística correlacional Correlação de Pearson - dos dados foi possível verificar que houve uma correlação significativa entre as variáveis IG com a subescala hiperatividade, indicados pelo SDQ Pa (R= -,465*), correlação entre IG e peso ao nascer com a subescala hiperatividade, indicados pelo SDQ Pr ( R= -,528**; R= - ,429*, respectivamente). Todas essas correlações se apresentaram significativamente negativa o que corrobora com os achados da literatura, isto é, quanto menor a IG e peso ao nascer, maiores são as chances de apresentarem problemas comportamentais sugestivos de TDAH. Foi possível verificar também, que pais e professores avaliaram de forma semelhante o desenvolvimento das crianças. Conclui-se assim, que crianças com histórico de nascimento prematuro e baixo peso apresentam sinais sugestivos de TDAH aos 3 anos de idade, e que a realização de triagem para detectar precocemente estes sinais facilita a intervenção terapêutica e pode com isso reduzir o impacto no desempenho acadêmico de escolares com histórico de nascimento prematuro extremo e baixo peso.

Contexte: Le retard de croissance intra-utérin (RCIU) désigne l’incapacité du fœtus à atteindre son potentiel de croissance déterminé génétiquement en raison de diverses causes. Il est défini le plus souvent par un poids de naissance inférieur au 10ème percentile pour l’âge gestationnel sur les courbes néonatales. Ce travail de thèse a comme objectif de répondre aux questions non-résolues sur la définition et les conséquences du RCIU dans le contexte de la grande prématurité: (1) Quelle est la meilleure définition du RCIU à utiliser pour identifier les enfants à risque ? (2) Quels sont les risques de mortalité et de morbidités néonatales respiratoires et neurologiques associés au RCIU et existe-t-il des interactions avec les pathologies de la grossesse responsables de cette naissance très prématurée ? (3) Quel est l’impact du RCIU sur le devenir neuro-développemental à 2 ans, en particulier chez les enfants nés extrêmement prématurément ? Méthodes: Nous avons utilisé deux sources de données. L’étude MOSAIC (Models for OrganiSing Access to Intensive Care for Very Preterm Babies in Europe) est une étude européenne en population qui porte sur l’ensemble des naissances survenues entre 22 et 31 semaines d’aménorrhée en 2003 dans dix régions européennes. Les enfants ont été suivis jusqu’à la sortie d’hospitalisation (population d’étude : 4525 enfants). La deuxième source est une cohorte d’enfants nés avant 27SA qui ont été hospitalisés dans le service de réanimation néonatale à l'hôpital de Port-Royal de 1999 à 2008 et qui ont eu un examen pédiatrique et une évaluation selon l’échelle de Brunet-Lézine qui inclut quatre domaines du développement global de l’enfant : la motricité globale, la motricité fine, le langage et l’interaction sociale (445 enfants admis, 268 enfants suivis à 2 ans). Résultats: Dans les deux populations, les risques de décès et de dysplasie broncho-pulmonaire étaient plus élevés pour les enfants ayant un poids de naissance <10éme percentile des courbes néonatales, mais également pour des enfants avec un poids plus élevé (entre le 10éme et le 24éme percentile des courbes néonatales ou <10ème percentile des courbes fœtales). Par contre, il n’y avait pas de lien entre les complications neurologiques et le faible poids, ni d’interaction avec les pathologies de la grossesse. Le RCIU était associé à un risque élevé du retard neurocognitif à deux ans d’âge corrigé chez les extrêmes prématurés, surtout dans le domaine de la motricité fine et de l’interaction sociale mais pas dans le domaine du langage et de la motricité globale. Nous n’avons pas trouvé d’association entre le RCIU et le risque d’infirmité motrice cérébrale à deux ans d’âge corrigé. Conclusions: L’utilisation du 10ème percentile des courbes néonatales n’est pas adaptée pour identifier l’impact du RCIU chez les grands prématurés ; l’utilisation de multiples seuils ou de courbes de croissance fœtale est nécessaire. Le RCIU accroit les risques de mortalité et de dysplasie broncho-pulmonaire, mais n’est pas associé aux lésions cérébrales sévères ; ces associations sont observées dans différents contextes périnatals (pathologies vasculaires et infectieuses, et naissances à des âges gestationnels très précoces). Le RCIU représente un facteur pronostic défavorable pour le neuro-développement à moyen terme. Nos résultats soulèvent de nouvelles questions sur le suivi adapté pour les enfants ayant un RCIU après leur sortie de l’hôpital et aussi sur les éventuels mécanismes biologiques pouvant expliquer les liens entre le RCIU avec une morbidité respiratoire et certains domaines du développement neurocognitif à moyen terme. / Background: Intrauterine growth restriction (IUGR) refers to the inability of the fetus to achieve its genetically determined growth potential due to various causes. Most often, it is defined by a birth weight less than the 10th percentile for gestational age using neonatal growth curves. This thesis aims to answer unresolved questions about the definition and consequences of IUGR in the context of very preterm birth: (1) what is the best definition of IUGR for identifying children at risk? (2) What are the risks of mortality and neonatal respiratory and neurological morbidity associated with IUGR and are there interactions with the underlying pregnancy complications responsible for the very preterm birth? (3) What is the impact of IUGR on neurodevelopmental at 2 years, especially for children born extremely preterm ? Methods: We used two data sources. The MOSAIC study (Models for Organising Access to Intensive Care for Very Preterm Babies in Europe) is a European population-based study that included all births occurring between 22 and 31 weeks of gestation in 2003 in ten European regions. The children were followed until hospital discharge (study population = 4525 infants). The second source is a cohort of children born before 27 weeks of GA who were hospitalized in the neonatal intensive care unit at the Port Royal Hospital from 1999 to 2008 and had a pediatric examination and Brunet-Lézine (BL) neurodevelopmental assessment at 2 years of corrected age (445 children in the cohort, 268children followed at 2 years). The BL assessment includes four areas of child development: gross motor, fine motor, language and social interaction skills. Results: In both populations, the risk of death and bronchopulmonary dysplasia were higher for children with a birth weight <10th percentile of neonatal growth curves but also for children with a higher birth weight (between the 10th and the 24th percentile of neonatal growth curves or <10th percentile of fetal growth curves). In contrast, there was no link between neurological complications and low birth weight and no interactions with pregnancy complications. IUGR was associated with neurocognitive delay among extremely preterm children evaluated at two years of corrected age, especially for fine motor and social interaction skills, but not for language and gross motor skills. We did not find any association between IUGR and the risk of cerebral palsy at two years of corrected age. Conclusions: The use of the 10th percentile of neonatal growth curves is not suitable for identifying the impact of IUGR in very preterm infants; using higher thresholds or fetal growth curves is necessary. IUGR increased the risks of mortality and bronchopulmonary dysplasia, but was not associated with severe brain damage; these associations are observed in multiple clinical contexts (vascular and infectious pregnancy complications, and births at very early gestational ages). IUGR is a risk factor for poor medium-term neuro-development. Our results raise new questions about the appropriate surveillance for children with IUGR after discharge from the hospital and also about possible biological mechanisms that could explain the relationship between IUGR and respiratory morbidity and neurocognitive development.