Journal of Neonatology & Clinical Pediatrics Category: Clinical Type: Research Article
Effects of Early Intervention on the Language of Mexican and Galician Preterm Infants
- Donna Jackson-Maldonado1*, Miguel Perez-Pereira2, Gloria Avecilla Ramirez3, Lauren M Cycyk4, Melissa Calderon Carrillo5, Jose Luis Fernandez-Trisac6, Maria Luisa Gonzalez-Duran7
- 1 Facultad De Lenguas Y Letras, Casa Fray Junipero Serra Queretaro-8, Universidad Autonoma De Queretaro, Santiago De Queretaro, Queretaro, Mexico
- 2 Department Of Pediatrics, Universidad De Santiago De Compostela, Santiago De Compostela, Spain
- 3 Department Of Neonatology, Universidad Autonoma De Queretaro, Santiago De Queretaro, Mexico
- 4 Department Of Pediatrics, University Of Oregon, Eugene, OR, United States
- 5 Facultad De Lenguas Y Letras, Universidad Autonoma De Queretaro, Santiago De Queretaro, Mexico
- 6 Department Of Neonatology, Complejo Hospitalario Universitario De Coruna, A Coruna, Spain
- 7 Department Of Neonatology, Complejo Hospitalario Universitario De Vigo, Galicia, Spain
*Corresponding Author:Donna Jackson-Maldonado
Facultad De Lenguas Y Letras, Casa Fray Junipero Serra Queretaro-8, Universidad Autonoma De Queretaro, Santiago De Queretaro, Queretaro, Mexico
Tel:+52 442 2180264,
Received Date: Aug 13, 2016 Accepted Date: Mar 15, 2017 Published Date: Mar 29, 2017
In Mexico, there is a large discrepancy concerning the rate of premature births. The percentage of premature births reported ranges from 4.1 to 19.7% to depending on the state and the level of poverty being considered [3,4]. In Spain, it has been reported that approximately 7.4% of births are PR [2,5].
Despite medical advances, with differences in each country, there is still a large percent of PR infants who are at risk for brain damage or developmental disorders including difficulties with cognitive, motor and linguistic development [6-11]. In fact, it has been noted that PR infants are 50% more likely than Full Term (FT) infants to be enrolled in special education programs later in life [12,13].
FACTORS THAT AFFECT DEVELOPMENT
Additional medical risk factors associated with PR include bronchopulmonary dysplasia, germinal matrix intraventricular hemorrhage, posthemorrhagic hydrocephalus, and Periventricular Leukomalacia (PVL). Environmental factors, such as socio-economic status, maternal affect and family context have also been found to affect PR infants’ risk [18-20]. Of these factors, of particular interest for this study is the effect of PVL.
PVL is a frequent type of lesion found in the brains of PR infants , consisting of white matter lesions surrounding the ventricles. This condition is identified by neuro-resonance imaging (fMRI) or by cranial ultrasound at birth. PLV can be classified by different degrees of severity. However, many studies do not clearly identify which type of PVL is present in the populations that are observed as not all PR infants are submitted to neuroimaging, the only currently available means for detecting PVL. This diagnostic distinction is important, as there are large differences in infants’ outcomes depending on the degree of lesion. For example, long-term cognitive and linguistic developmental effects have been associated with non-cystic PVL with diffuse lesions [17,22,23], whereas Cerebral Palsy is mostly correlated with focal necrotic lesions of PVL deep in the cerebral white matter . Diffuse or Non-Cystic PVL (NC-PVL) may have symptoms that are not easily detected whereas the sequels of severe or cystic PVL are highly related to Cerebral Palsy.
EFFECT OF PREMATURITY ON LANGUAGE DEVELOPMENT
Thus, there are no definite conclusions, and further studies are merited that differentiate risk characteristics. As most risk has been found in extreme populations of PR births, such as very and extremely premature infants, other groups need to be studied, such as moderate and late PR [7,11,18,37,38]. Another factor that affects development is the rate and type of early intervention the infant receives and this also needs to be studied in more depth. This study addresses early intervention in late preterm infants.
There is inconsistent evidence to show the effects of early intervention on birth weight, gestational age, risk or type of intervention as many times these factors are not controlled for or are not reported in participant descriptions [12,16,35,37,38,43-50]. Another important finding of these studies is that strong positive effects of the intervention were observed later in childhood that may not have been apparent at early ages [33,44].
The cited research projects are based on social and cognitive interventions that are not the goal of our study. Here we are interested in the effects of a dynamic motor as well as language intervention. Static and dynamic methods of physical therapy differ on premises of the infant’s direct participation. The Bobath or Neurodevelopmental Therapy (Bobath or NDT) is a frequently used dynamic method, mostly in children with Cerebral Palsy. Several studies have shown that children advanced significantly in the Gross Motor Function Measure, motor reflexes as well as in self care [51-54]. Only one study to date, to our knowledge, has studied PR infants receiving Bobath using clinical trials . Significant differences were found between the preterm treatment group and both control groups in posture, behavior and solicited items.
Another, less well known dynamic method is the Katona system [56-62]. It differs from the Bobath in the type of manipulation and specific technique, but the goal of having the infant respond actively to the movements is similar. Both interventions begin immediately after birth and target muscle tone control and posture as well as active participation of the caregivers [53,63,64]. Specific aspects of the technique and type of manipulation differ. The Katona method has a recent efficacy reports with PR infants . Here two groups of preterm infants under 2 months of age were seen: with and without neurohabilitation intervention. Results showed that the group with intervention had a higher percent of children with normal neurodevelopmental outcomes than the non-treated group (90%). Two other studies have shown changes in neurological and motor functions for PR infants 6 to 8 months after intervention [65,66].
Based on extensive previous research cited above it has consistently been shown that PR infants may have cognitive and linguistic delays. The effect of intervention has been explored, though to a lesser degree in PR infants and only a handful of studies exist for Spanish-speaking children. Much less, is there evidence for the efficacy of dynamic motor treatment on the infant’s language development.
PURPOSE OF THE STUDY
All participants in this study were part of larger projects in which multiple aspects of development were assessed with different instruments. Data using the other instruments have been published elsewhere [18,29,67,68,69]. Here we will only concentrate on results from the parental report of communicative abilities.
The three cohorts of PR infants were between 10 and 14 months corrected age. The Galician cohort was included in order to contrast infants who had not received intervention as these were not readily available in Mexico. Most were followed from birth, but data at later dates is not available because children no longer participated in the project. Risk factors were controlled for and samples were similar at birth excluding the variables that were part of the study, like NC-PVL. Social and medical factors were similar (see below). The FT sample, Group 1 (GP1), was a referential group of Galician healthy, full term infants [18,68,70]. It consisted of 49 infants who were 10 months of age.
Group 2 (GP2) consisted of 32 Galician PR infants without NC-PVL or other relevant medical complication. These infants did not receive any post NICU intervention as it was not part of the hospital protocol. All infants were 10 months of age at the time of data collection.
Groups 3 and 4 were Mexican PR infants who were in different types of intervention. Group 3 (GP2) included 15 PR Mexican infants between the ages of 10 and 14 months who were diagnosed with NC-PVL and received Katona therapy (see above) in the first weeks after birth. They were part of the protocol of a research project at the XXX in which only Katona therapy was given. Group 4 (GP4) consisted of 30 PR Mexican infants with NC-PVL, between the ages of 10 and 14 months, who received Katona therapy and were also in an early post NICU intervention language program that was developed explicitly for the XXX center. Participants from Group 3 and 4 were randomly selected to participate in either type of intervention as they were part of different stages of a larger research project.
Mother’s educational level across for the Galician sample was mostly of High School and above (GP4 or FT = 61%, GP2, PR with no NC-PVL = 84%) for both PR and FT infants [18,68] with a slightly higher educational level in the PR group. The Mexican samples were also predominantly composed of more than High School educated mothers (GP2 = 77%, GP3 = 76%) Thus, all samples consisted mostly of parents who had educational levels of High School or above educational.
Table 1 presents descriptive information for each group of infants. It should be noted that not all descriptive statistics were run for corrected age for GPs 1 (full term) and 2 (PR with no intervention), as all children were seen at 10 months of age (plus or minus 15 days). A t test of independent measures yielded no significant differences (p = .41) between the other two PR (motor and motor and language intervention) groups for corrected age (GP3, M = 11.4, SD = 1.6; GP4, M = 10.7, SD = 1.31). All groups were compared for gender, Birth Weight (BW) and Gestational Age (GA). The groups were equivalent in gender proportion (p = .508). Birth weight (BW) in kilos, as would be expected, was significantly lower in all the PR groups than in the FT group, F(3,120) = 133, p < .001, ω2 = 0.762. No significant differences were found within the three PR groups for BW, F(2,72) = 1.2, p = .285 or for GA F(2,72) = 1.4, p = .23 (Table 1).
|N||Corrected Age||Gestational Age||Weight at Birth||%prod (SD)||% comp (SD)|
|GP1||32||10 (0)||30.8 (2.89)||1.44 (444)||1.29 (1.96)||20.83 (17.97)|
|GP2||15||10.7 (1.31)||32.9 (2.22)||1.64 (696)||1.36 (1.54)||33.86 (13.59)|
|GP3||30||11.4 (1.60)||30.9 (2.86)||1.65 (670)||2.75 (3.10)||37.88 (19.23)|
|GP4||49||10 (0)||39.8 **||3.38 (415) **||1.66 (5.72)||18.71(15.30) *|
% prod (SD) = Percent produced of total words on CDI (Standard Deviation), % comp (SD) = Percent comprehended of total words on CDI (Standard Deviation).
Another issue that was considered in the instrument selection, to best appreciate language development, was in line with the literature that has consistently has shown variability in vocabulary development within age groups. There is also robust data showing that in language development variability across all age ranges is the norm rather than the exception . Nelson , based on an ample sample of toddlers, proposed that individual differences and variability manifested by different learning styles (including number and types of words) should be considered when analyzing language development, but all within certain milestones. Contrary to medical tests, language tests should illustrate these differences within groups with evidence based cut-off points to determine risk. As shown in Fenson et al.,  the MBCDIs do reflect this expected variability.
The Galician and Spanish versions of a parental report, the MBCDI Palabras e Xestos or Primeras Palabra y Gestos (First Words and Gestures) [80-82] were used in this study. Parental report measures, such as these, have been shown to be adequate measures to determine communicative development at very early stages of development and with preterm infants . Parents of all children filled out the forms for their specific language (Galician or Spanish) at home, in the hospital or during visits to the university clinics. A brief explanation was given to parents that included the difference between comprehension and production, word variations because of pronunciation, contexts in which words are used, etc. In this study, we will only report on the vocabulary comprehension and production sections of these measures. The Galician form consists of 384 words whereas the Spanish form has 428 words. In order to equate scores, rather than report raw scores or percentiles, we calculated percent of words identified by parents.
Infants in the Galician study were part of a larger longitudinal study [18,68,81]. Families were initially contacted through the hospital setting and asked to participate. Infants were not in early intervention programs after hospital discharge. At 15 days of age (after birth) the infants were evaluated with the Neonatal Behavioral Assessment Scale (NBAS) [84,85]. Preterm infants scored higher in motor and range of state cluster, while FT infants had higher scores in regulation of state clusters. At that time, the mothers of the infants participated in a long interview in which family environment and general health information was obtained for each child. For the Galician group, exclusionary criteria for this sample included Cerebral Palsy (as diagnosed up until 9 months of age), Periventricular Leukomalacia (PVL), Intraventricular Hemorrhage (IVH) greater than grade II, hydrocephalus, encephalopathy, genetic malformations, chromosomal syndromes, metabolic syndromes associated to mental retardation, or important motor or sensorial impairments.
The PR Mexican sample was obtained as part of another large study at the Unidad X [67,70]. Two different samples were obtained from different project within the center and were independently assigned to each study. Infants participated in a range of neuropsychological tests, and the Bayley Scales  was used as a neurodevelopmental measure. Infants with scores that showed significant delays on the neurodevelopmental measures and motor or sensorial impairments were not included. The motor intervention sample (GP3) was part of the initial research project at the XXX whereas the GP4 (motor and language intervention) infants participated in the early intervention program that was developed as part of a specific research project . Before the study, when infants were between 42 and 46 weeks of age (corrected) a clinical neuropediatric assessment  was carried out to identify non-normal neuropsychological signs that could be signify problems other than NC-PVL. Magnetic Resonance Imaging (fMRI) using a Phillips Intera of 1 Tesla was completed in order to diagnose NC-PVL, which was an inclusionary criterion for both Mexican samples. A clinical EEG was also obtained for all infants to determine whether electrical cerebral activity was normal. Visual and Auditory Evoked Potentials (VEPs and AEPs) were intact. Infants with cystic PVL, cerebral hemorrhages, brain infarcts, brain malformations or other pathological lesions apart from diffuse PVL were excluded.
The motor intervention that both Mexican groups (GP3 and GP4) received was based on Katona neurohabilitation [56,57,62]. Intervention began immediately after birth and continued throughout the study to take advantage of the plasticity of the central nervous system. Sessions were held on a weekly basis with active parental participation encouraged. Exercises were continued at home, as well.
In addition, GP4 also received early language intervention, along with the motor intervention. Mothers met individually with a certified speech-language pathologist biweekly for a total of 12 hourly training sessions focused on enriching infant communication development and parent training [88,89]. Intervention began, again, at birth or within the first month of age. Targeted topics included: (1) understanding the course of typical language development; (2) increasing sensitivity to the infants’ cues [88,89]; (3) creating a supportive environment for learning and growing; (4) applying focused stimulation [90,91]; (5) using infant-directed speech [50,92,93]; (6) increasing the quantity, quality, and responsitivity of communication ; (7) providing appropriate auditory stimulation ; and, (8) promoting early literacy experiences [96,97] Mothers first observed the speech-language pathologist using the targeted strategies with their infants. They then applied the same strategies with their infants while receiving immediate verbal and visual feedback to improve their interactions. In addition, an easy-to-read information sheet on each topic was provided in order to facilitate home review of the topic. Mothers were assigned work to do at home between training sessions in order to facilitate continued practice of the communication strategies in the home environment. The last training session was a review of all presented topics by means of a questionnaire.
We first examined gender effects and as no differences were found we did not consider gender in the rest of the analysis. Birth weight (BW) and Gestational Age (GA) effects were also analyzed in the first three groups to determine homogeneity. As groups were similar and our goal was not to analyze effects of these medical factors, further analysis will not be reported here for these variables. The rest of the analysis that was carried out was to determine the effect of three levels of intervention (GP2-no intervention, GP3-motor only and GP4-motor plus language) on vocabulary comprehension and production. As mentioned previously, percent reported scores for words comprehended and produced were calculated. Descriptive data for vocabulary comprehension and production are reported in Table 1.
Table 1 presents descriptive information for each group of infants. It should be noted that descriptive statistics were not run for corrected age for GPs 1 and 2, as all children were seen at 10 months of age (plus or minus 15 days). A t-test of independent measures yielded no significant differences (p = .41) between the other two PR groups (with intervention) for corrected age (GP3, M = 11.4, SD = 1.6; GP4, M = 10.7, SD = 1.31).
Tests on vocabulary measures were run to determine differences between groups. As would be expected, there were significant differences between language comprehension and production, F(1,3) = 285.862, p < .001, ?p2 = 0.704). There was also a main effect of group, F(3,120) = 10.952, p < .001, ?p2 = 0.177. Next, the effects of intervention on both comprehension and production were analyzed. There was a significant interaction between group and repeated measures factor (comprehension and production), F(3,120) = 7.317, p < .001, ?p2 = .215. A post-hoc Bonferroni correction revealed significant differences between GP2 (PR, no intervention) and GP4 (PR, language and motor intervention) (p < .001), and between GP4 (PR, language and motor intervention) and GP1 (full term) (p < .001). The effects of intervention were strongest between the PR group that received no intervention and the combination of both language/motor intervention groups (p < .001) for both comprehension and production. What is interesting is that there was a significant difference favoring PR infants when compared to FT infants. Thus, early stimulation seems to have an impact on language development in general.
There was a larger effect on comprehension than on production (Figures 1 and 2). A one way ANOVA test for each language module (comprehension and production) yielded a significant difference between groups only in comprehension, F(3,120) = 10.012, p < .01 ω2 = .179. A Bonferroni post-hoc revealed significant differences between GP2 (PR, no intervention) and GP4 (PR, language and motor intervention) (p < .001), between GP4 (PR, language and motor intervention) and G1 (full term) (p < .001), and between GP3 (PR, motor intervention) and G1 (full term) (p < .001). No significant differences were found for vocabulary between GP 2 (PR, no intervention) and GP3 (PR, motor intervention). Thus, it appears, as would be expected because of the young age, that intervention had a stronger effect on comprehension than on production. Production levels were very low at this age and, thus any effects may be a product of the scarcity of vocabulary.
DISCUSSION AND CONCLUSION
One of the major issues at stake in this paper is the effect of early intervention on language development. As previously noted, there is scant literature on the effects of intervention in preterm Spanish-speaking samples, and much less on the effect of Katona and early language intervention programs. The available literature has stated that early intervention, of multiple types, has a positive effect on later development [37,44]. Some studies have analyzed specific intervention programs, but seldom, if ever, consider the relationship between physical or motor and language intervention. In this paper we explored a dynamic physical therapy system for which little evidence has been reported and a language intervention program that has parameters similar to programs previously reported on in the literature [88,89,98]. Our results illuminate differences based on intervention types and for language comprehension and production.
We first explored socio-economic and medical characteristics of our populations to determine if there were differences among groups. Most mothers had more than High School education, thus this socio-economic factor was not a variable that was included in the analysis. Mother’s education, as a means for analyzing socio-economic status is a determining factor in this and most populations. The fact that our sample was restricted in this sense is a limitation of the study and does not allow for extensive generalizations. Medical aspects, particularly birth weight and gestational age were also homogenous across groups and, thus, were not further explored. The goals of the study were restricted to a more homogeneous sample, and thus, effects from these variables were not measured. Also, it is possible, as proposed in other studies, that differences may appear at later stages of development [28,33,99] or only for infants with extremely low birth weight or gestational age who are at higher risk for language development problems. Both of these issues merit more in depth analysis that should be the focus of future research that includes longitudinal samples.
This discussion will concentrate on the main purpose of our study, to analyze differences in comprehension and production of early vocabulary based on different types of intervention. All results clearly reflect variability within the sample. This would not suggest a defect of the instrument, but rather support what has been proposed in language development research [71,77]. It must be recalled, as well, that vocabulary production is very low at the ages studied, regardless of premature birth or its associated complications . Longitudinal studies could possibly answer questions related to later effects of prematurity on language production. At these early ages (10 to 14 months), effects may not yet be present. Thus, comprehension data may best answer our research questions. Results, taking into account post-hoc calculations, indicated that vocabulary scores were related to the type of intervention received. We must recall that GP 4 (PR with language and motor intervention) participated in an early language intervention program that underscored parental participation along with specific interactional components thought to boost communicative skills. This group had the highest vocabulary scores. In all cases, and as is expected because of the young age of the participating infants, there were larger effects for comprehension than for production.
When taking into account the motor intervention group (GP3), based on our hypothesis, we would have also expected higher scores in in their vocabulary when compared to the no-intervention (GP2) group. Contrary to our hypothesis, Group 3 was not significantly different when comparing it to the other groups. It is possible, as reported elsewhere , that effects could be found for neurodevelopmental factors, though not for vocabulary development. To further explore this relation, a larger, more diverse sample, would be required as it is has been shown that motor development is related to language [100,101].
Although statistical results are extremely important, tendencies can be observed in figures 1 and 2 that illustrate percent number of words. Here we can see that both groups that receive intervention had higher scores (though not all have significant differences) than both the FT term and the no-intervention (GP2) groups in language comprehension. There does seem to be a different pattern for language production. In this case the FT group is similar to the language intervention group (GP4). We must take into consideration, as well, that both GP3 and GP4 were at a slight medical risk as they were identified with NC-PVL. Still, their language scores were found to be higher than infants who were not experiencing this risk factor, and who received no intervention.
To our knowledge, this is the first study of its kind study to explore the effect of different modalities of intervention on early communicative skills in preterm infants. We propose that early interventions that combine motor and language training techniques, particularly with high parent participation, can have effects on language outcomes in the first year of life.
One apparent weakness of this research is that we did not obtain language measures prior to administering the intervention. As a result, we do not know with certainty if the four groups were comparable in their initial language abilities. However, it is necessary to take into consideration that few, if any, reliable language measures are available for children younger than 8 months of age because children’s first words usually appear between 10 and 12 months of age [71,102]. Further, data from other behavioral and observational language measures could add to the understanding of the infant’s communicative abilities. Follow up studies when the infants are older could also be beneficial. This would entail creating large longitudinal cohorts with more diverse populations, as well to the effect of maternal education or other factors on the communicative abilities of PR infants. There is a need for such research.
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Citation:Jackson-Maldonado D, Perez-Pereira M, Ramírez GA, Cycyk LM, Carrillo MC et al. (2017) Effects of Early Intervention on the Language of Mexican and Galician Preterm Infants. J Neonatol Clin Pediatr 4: 018.
Copyright: © 2017 Donna Jackson-Maldonado, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.