Movement Assessment Battery for Children (Movement-ABC) – Article Summary
Schmidt B, Roberts RS, Anderson PJ, et al. Academic Performance, Motor Function, and Behavior 11 Years After Neonatal Caffeine Citrate Therapy for Apnea of Prematurity: An 11-Year Follow-up of the CAP Randomized Clinical Trial. JAMA Pediatr. 2017;171(6):564–572. doi:10.1001/jamapediatrics.2017.0238
Purpose
Preterm infants are often dealt a poor hand, including the possibility of battling apnea; if left untreated, apnea can result in a multitude of functional impairments and possibly death. It is well known that caffeine citrate is a drug of choice to combat the affects of apnea on preterm infants. The purpose of this study was to determine the effectiveness of caffeine citrate therapy on premature infants through 11-12 years old, using three functional outcomes: academic performance, motor function, and behavior.
Study population
This study investigated these effects on 920 children, aged 11-12, across 14 academic hospitals from 2011 to 2016 who had previously been studied in a placebo-controlled double-blind trial using caffeine citrate therapy for apnea between 1999 and 2004. Infants who had congenital abnormalities, deemed unlikely to participate in a follow-up, or who was already treated with methylxanthine were excluded from this study. Inclusion criteria included birth weight of 500-1250 grams and if clinicians supported mexthylxanthine therapy during the first 10 days of life as appropriate.
Methods
The initial study performed between 1999 and 2004 was when either caffeine citrate or placebo (saline) therapy was introduced as early as 3 days old with administration of 20 mg/kg body weight with a daily dosage of 5 mg/kg body weight. After 35 weeks, the infant was taken off the caffeine or placebo. This follow up study investigated these children between 11 and 12 years old and the researchers were unaware of if the participant was introduced to the caffeine citrate or placebo during the initial study.
Outcome measures
Outcome measures included the Movement Assessment Battery for Children-Second Edition (MABC-2) to measure motor skills, Child Behavior Checklist to measure behavior problems, and the Wide Range Achievement Test-4 to measure academic performance. Scoring in the 5th percentile or less on the MABC-2 were indicative of motor impairment. Scoring higher on MABC-2 indicates better performance.
Intervention
Because this was a follow up study of the initial study where the intervention of caffeine citrate therapy was utilized, this study doesn’t have a particular intervention; rather, it is investigated the effects of caffeine citrate therapy on motor function, academic performance, and behavior later in life (11-12 years old).
Results
The results of this study indicate that there is no significant difference in reducing the combined rate of functional impairments with use of caffeine therapy for preterm infants; however, there is benefits of caffeine therapy for motor function and is indicated as a safe form of treatment for low weight infants to treat apnea and prevent confounding impairments of motor function. Furthermore, participants from the caffeine therapy group had significantly improvement in dexterity (p=0.01), balance (p=0.005), and overall motor performance (p=0.005) compared to the placebo group.
Strengths
The author suggests that the sample size of 920 of the 1202 children may result in ascertainment; however, a sample of 920 individuals who have been in a longitudinal study such as this is a strength, as it is difficult to study and perform safe interventions from 3 days old and record data until 12 years old. Along with a large sample size, being a double-blind trial is a strength as it helps reduce bias from the researcher and further reduce a placebo effect. Although majority of the subjects reviewed appeared to be healthy, there were limited individuals with cerebral palsy, blindness, deafness, or another form of disability. This variety helps capture a wider spectrum of patient population.
Limitations
It is difficult to isolate caffeine therapy as the only source of improvement for motor function. The author suggests that cognitive improvements are from social and environmental sources; how much of motor function can be attributed to those as well rather than caffeine citrate? To improve statistical power and strengthen the hypothesis that caffeine therapy improves motor function in preterm infants, additional reliable and valid outcome measures other than MABC-2, would be suggested.
Conclusion
Overall, this article investigates a relative and fascinating research question with good statistical analysis and formulates good discussion for long term effects of caffeine therapy on preterm infants. The outcome measures used are valid and reliable as they entail three of the most functional questions for children aged 11-12 (motor impairments, academic performance, behavior). Moreover, the authors do a good job of eliminating bias with a double-blind trial. This article further justifies the support for use of caffeine citrate therapy to battle apnea for premature infants and associated with improvement in motor function compared to placebo.
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