Positive Screening for Autism in Ex-preterm Infants: Prevalence and

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Screening positivo para autismo em
ex-pré-termos : Prevalência e risco
(Positive Screening for Autism in Ex-preterm Infants:
Prevalence and Risk)
Catherine Limperopoulos, PhDa,b, Haim Bassan, MDb, Nancy R. Sullivan, PhDc, Janet S.
Soul, MDb, Richard L. Robertson, Jr, MDd, Marianne Moore, BA, RNb, Steven A. Ringer,
MD, PhDe, Joseph J. Volpe, MDb and Adré J. du Plessis, MBChB, MPHb
a Department of Neurology and Neurosurgery, School of Physical and Occupational Therapy, and
Department of Pediatrics, McGill University, Montreal, Quebec, Canada
b Fetal-Neonatal Neurology Research Program, Department of Neurology
c Developmental Medicine Center
d Department of Radiology, Children's Hospital Boston and Harvard Medical School, Boston,
Massachusetts
e Department of Neonatology, Brigham and Women's Hospital and Harvard Medical School, Boston,
Massachusetts
Pediatrics 2008;121;758-765 (April 2008)
Apresentação:Juliana Sobral Coutinho
Paulo Henrique G. Pereira
Coordenação: Paulo R. Margotto
www.paulomargotto.com.br
14/4/2008
Introdução
• Avanços
no
tratamento
intensivo
de
neonatologia aumentaram a sobrevivência de
pré-termos, no entanto houve redução da
morbidade neurológica e do desenvolvimento a
longo prazo.
• 50% de ex-pré-termos apresentam dificuldades
na função executiva, atenção e comportamento.
• Baixo peso e idade gestacional são fatores de
risco perinatais.
• A prevalência dos distúrbios do expectro do
autismo ainda não foi sistematicamente
explorada na população dos pré-termos.
Objetivo
Aplicar testes de rastreamento para
características autísticas em crianças
com história de muito baixo peso ao
nascer e identificar fatores de risco
associados ao resultado positivo do
rastreamento.
Metodologia
• Coorte de recém-nascidos fazia parte de
um estudo prospectivo sobre função
cerebrovascular numa série consecutiva
de pré-termos menores de 1500g
• Foram excluídos aqueles com disgenesia
cerebral,
síndromes
dismórficas
e
cromossomopatias
• Total: 91 RN.
Metodologia
• Modified Checklist for Autism in Toddler (MCHAT) foi aplicado nos RN entre as idades de
18 a 24 meses ajustados pela prematuridade.
• A informação psicométrica do M-CHAT
demonstra altas especificidade e sensibilidade.
• Child Behavior Checklist (CBCL) foi aplicada
para avaliar problemas comportamentais e
emocionais.
• Vineland Adaptive Behavior Scale (VARS) foi
aplicada para avaliar as funções adaptativas:
comunicação, socialização, motricidade
Metodologia
• Amostra caracterizada quanto aos aspectos demográficos, prénatais, intra-parto, pós-parto imediato, resultado a curto prazo.
• Dentre tais variáveis, foram identificados como possíveis variáveis
preditoras de positividade no rastreio de autismo
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Idade materna
Temperatura materna
Hemorragia intra ou ante-parto
Parto prematuro
Infecção da placenta
Idade gestacional
Peso ao nascer
Sexo
Pontuação no SNAP II
Duração da necessidade de oxigênio
Ressonância Magnética alterada
Realizada Análise da Regressão Logística Multivariada para
identificar o modelo predictivo final
Resultados
• Idade gestacional variou
de 23 a 30 semanas
• Peso
1490g
variou de 460 a
Resultados
• Correlação altamente positiva entre pontuação anormal no M-
CHAT com problemas de introspecção do CBCL
• Correlação positiva entre dificuldades de socialização e de
habilidades de comunicação com resultado positivo do MCHAT.
Resultados
Resultados
Análise da Regressão Logística Univariada
Resultados
Análise da Regressão Logística Multivariada
Discussão
• Elevada prevalência de características
autísticas nos pré-termos extremos
sobreviventes.
• Correlação positiva entre resultado
positivo do M-CHAT e introspecção e
problemas de socialização e déficits de
comunicação.
• Primeira descrição desse fenômeno em
prematuros extremos
Discussão
• Estudos
populacionais
identificaram
prematuridade, baixo peso e necessidade
de tratamento intensivo neonatal como
fatores de risco perinatais para espectro
autista.
• Tais fatores atuariam independentemente
ou interagiriam com a predisposição
genética por interferir em pontos críticos
do desenvolvimento.
Discussão
• Corioamnionite e sexo masculino são fatores já
identificados como fatores associados a autismo
• Limitações:
– M-CHAT é um instrumento de rastreio, não fecha o
diagnóstico
– Como foi aplicado aos 18 meses, as alterações
podem ser transitórias ou podem emergir a partir
dessa idade.
– Ausência de dados socioeconômicos, já que estes
podem justificar atraso do desenvolvimento.
– Amostra altamente selecionada.
Conclusão
Os resultados desse estudo sugerem que o
rastreamento precoce para sinais de
autismo são justificados em uma população
de prematuros extremos seguido por um
teste definitivo para autismo naqueles com
teste inicial positivo.
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ABSTRACT
OBJECTIVE. The survival of very low birth weight infants has increased markedly in recent
years. Unfortunately, the prevalence of significant and lifelong motor, cognitive, and
behavioral dysfunction has remained a major problem confronting these children. The
objective of this study was to perform screening tests for early autistic features in children
with a history of very low birth weight and to identify risk factors associated with a positive
screening result.
METHODS. We studied 91 ex-preterm infants 1500 g at birth. Infants underwent
conventional MRI studies at preterm and/or term-adjusted age. We collected pertinent
demographic, prenatal, intrapartum, acute postnatal, and short-term outcome data for all
infants. Follow-up assessments were performed at a mean age of 21.9 ± 4.7 months, using
the Modified Checklist for Autism in Toddlers, the Vineland Adaptive Behavior Scale, and the
Child Behavior Checklist.
RESULTS. Twenty-six percent of ex-preterm infants had a positive result on the autism
screening tool. Abnormal scores correlated highly with internalizing behavioral problems on
the Child Behavior Checklist and socialization and communication deficits on the Vineland
Scales. Lower birth weight, gestational age, male gender, chorioamnionitis, acute intrapartum
hemorrhage, illness severity on admission, and abnormal MRI studies were significantly
associated with an abnormal autism screening score.
CONCLUSIONS. Early autistic behaviors seem to be an underrecognized feature of very low
birth weight infants. The results from this study suggest that early screening for signs of
autism may be warranted in this high-risk population followed by definitive autism testing in
those with positive screening results.
Key Words: autism • prematurity • MRI • risk factors • outcome
Abbreviations: VLBW—very low birth weight • M-CHAT—Modified Checklist for Autism in
Toddlers • CBCL—Child Behavior Checklist • VABS—Vineland Adaptive Behavior Scale •
SNAP-II—Score of Neonatal Acute Physiology II • PVL—periventricular leukomalacia •
PVHI—periventricular hemorrhagic infarction
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Obrigado!!!
Ddo Paulo Henrique, Dra. Juliana e Dr. Paulo R. Margotto
14/4/2008
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