Given the prevalence of preterm birth, all pediatric speech-language pathologists (SLPs) will work with children who were born preterm. Although most children born preterm do not experience developmental problems, more will experience feeding and language problems, arid, to a lesser extent, voice, and speech problems, than children born at term, often in the context of broader developmental and medical concerns. As SLPs examine, assess, and treat children who are preterm post-hospital discharge and into the early years of life and beyond, they will benefit from a more holistic understanding of this population's developmental challenges across domains. In this review, we will discuss the medical, social, and developmental underpinnings to working with a child born preterm in addition to describing the background and current evidence for assessing and treating feeding, language, speech, voice, and fluency disorders in this population.

Purpose: Around 9% of children have difficulty acquiring intelligible speech despite typical sensory, neuro-motor and cognitive function. Speech-language pathologists (SLPs) rely on descriptions of children's speech errors to identify speech sound disorder (SSD) and determine intervention targets and goals. Existing normative data, however, need re-evaluation to reflect changes in populations and the language learning environment. This research evaluates whether developmental phonological patterns widely accepted as describing typical acquisition predict speech errors in a recent sample of preschool children. Method: In 2015, 99 neurotypical children aged 3;0-3;8 years;months were assessed using the Diagnostic Evaluation of Articulation and Phonology (DEAP). Their performance was compared to studies describing speech development by children of the same age for phone repertoire and phonological patterns. Result: There were differences for both measures. Phone repertoire differences were marginal, but changes in phonological pattern use were unexpected. Suppression of three developmental phonological patterns (stopping of fricatives, final consonant deletion and voicing contrasts) was delayed compared to previous norms. Atypical consonant cluster reduction, sometimes considered a marker for disorder, was observed in 10% of children. Conclusion: There were qualitative differences in the speech development of the 2015 cohort of children compared to previous developmental norms. Valid and current normative data are necessary for the accurate identification of children needing intervention. The differences we found reinforce the need for regular updating of assessment tools, as well as greater understanding of how children's language learning environments are changing and potentially influencing speech development.

Importance:Cerebral palsy (CP) is the most common childhood physical disability. Early intervention for children younger than 2 years with or at risk of CP is critical. Now that an evidence-based guideline for early accurate diagnosis of CP exists, there is a need to summarize effective, CP-specific early intervention and conduct new trials that harness plasticity to improve function and increase participation. Our recommendations apply primarily to children at high risk of CP or with a diagnosis of CP, aged 0 to 2 years. Objective:To systematically review the best available evidence about CP-specific early interventions across 9 domains promoting motor function, cognitive skills, communication, eating and drinking, vision, sleep, managing muscle tone, musculoskeletal health, and parental support. Evidence Review:The literature was systematically searched for the best available evidence for intervention for children aged 0 to 2 years at high risk of or with CP. Databases included CINAHL, Cochrane, Embase, MEDLINE, PsycInfo, and Scopus. Systematic reviews and randomized clinical trials (RCTs) were appraised by A Measurement Tool to Assess Systematic Reviews (AMSTAR) or Cochrane Risk of Bias tools. Recommendations were formed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework and reported according to the Appraisal of Guidelines, Research, and Evaluation (AGREE) II instrument. Findings:Sixteen systematic reviews and 27 RCTs met inclusion criteria. Quality varied. Three best-practice principles were supported for the 9 domains: (1) immediate referral for intervention after a diagnosis of high risk of CP, (2) building parental capacity for attachment, and (3) parental goal-setting at the commencement of intervention. Twenty-eight recommendations (24 for and 4 against) specific to the 9 domains are supported with key evidence: motor function (4 recommendations), cognitive skills (2), communication (7), eating and drinking (2), vision (4), sleep (7), tone (1), musculoskeletal health (2), and parent support (5). Conclusions and Relevance:When a child meets the criteria of high risk of CP, intervention should start as soon as possible. Parents want an early diagnosis and treatment and support implementation as soon as possible. Early intervention builds on a critical developmental time for plasticity of developing systems. Referrals for intervention across the 9 domains should be specific as per recommendations in this guideline.

Importance Cerebral palsy (CP) is the most common childhood physical disability. Early intervention for children younger than 2 years with or at risk of CP is critical. Now that an evidence-based guideline for early accurate diagnosis of CP exists, there is a need to summarize effective, CP-specific early intervention and conduct new trials that harness plasticity to improve function and increase participation. Our recommendations apply primarily to children at high risk of CP or with a diagnosis of CP, aged 0 to 2 years. Objective To systematically review the best available evidence about CP-specific early interventions across 9 domains promoting motor function, cognitive skills, communication, eating and drinking, vision, sleep, managing muscle tone, musculoskeletal health, and parental support. Evidence Review The literature was systematically searched for the best available evidence for intervention for children aged 0 to 2 years at high risk of or with CP. Databases included CINAHL, Cochrane, Embase, MEDLINE, PsycInfo, and Scopus. Systematic reviews and randomized clinical trials (RCTs) were appraised by A Measurement Tool to Assess Systematic Reviews (AMSTAR) or Cochrane Risk of Bias tools. Recommendations were formed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework and reported according to the Appraisal of Guidelines, Research, and Evaluation (AGREE) II instrument. Findings Sixteen systematic reviews and 27 RCTs met inclusion criteria. Quality varied. Three best-practice principles were supported for the 9 domains: (1) immediate referral for intervention after a diagnosis of high risk of CP, (2) building parental capacity for attachment, and (3) parental goal-setting at the commencement of intervention. Twenty-eight recommendations (24 for and 4 against) specific to the 9 domains are supported with key evidence: motor function (4 recommendations), cognitive skills (2), communication (7), eating and drinking (2), vision (4), sleep (7), tone (1), musculoskeletal health (2), and parent support (5). Conclusions and Relevance When a child meets the criteria of high risk of CP, intervention should start as soon as possible. Parents want an early diagnosis and treatment and support implementation as soon as possible. Early intervention builds on a critical developmental time for plasticity of developing systems. Referrals for intervention across the 9 domains should be specific as per recommendations in this guideline.

Evans syndrome (ES) is a rare condition characterised by the combination of autoimmune haemolytic anaemia and immune thrombocytopenia (ITP). While the precise pathophysiology is not entirely understood, it is thought that dysregulation of the immune system is a primary contributor to the condition. ES has been observed in viral infections including hepatitis C, cytomegalovirus, varicella zoster and Epstein–Barr viruses.1-4 Initial cases of coronavirus disease 2019 (COVID-19) were first described in early December 2019 and has now spread to a global pandemic. While knowledge about COVID-19 continues to evolve, clinicians have reported haematological complications associated with the virus. Presence of lymphopenia has been commonly reported in 35–40% of cases and appears to be associated with the development of acute respiratory distress syndrome.5-7 Thrombocytopenia and coagulopathies, including disseminated intravascular coagulation, have also been reported in cases of COVID-19, which were associated with more severe disease.8, 9 Here, we present the first case, to our knowledge, of COVID-19-associated ES and discuss its unique management issues. A 39-year-old man presented to the emergency department in late March 2020 with one day of haemoptysis and epistaxis in the setting of sore throat, productive cough, fevers, chills and dyspnoea lasting about 1 week. On evaluation, he was found to be febrile, tachycardic and tachypneic. Physical examination was notable for dried blood in the oropharynx and nares, as well as a blood blister in the mouth. He had no petechiae, ecchymoses or rash. Laboratory assessments demonstrated a leucocyte count of 11 000 cells/µl, haemoglobin of 156 g/l and platelet count of 3000 cells/µl. The neutrophil count was 8700 cells/µl, and lymphocyte count was 1700 cells/µl. Haemolysis laboratories were negative, and there were no schistocytes nor microspherocytes on peripheral blood smear. There was no infiltrate on chest X-ray. Rapid polymerase chain reaction assay for COVID-19 later returned a positive a result. On admission, the patient developed worsening bleeding with haematemesis, melena and haematochezia, associated with a haemoglobin decrease to 64 g/l. Intravenous proton pump inhibitor therapy was initiated, as well as daily intravenous immunoglobulin (IVIG) therapy for presumed ITP secondary to COVID-19. Glucocorticoids were not administered, as organisations such as the Centers for Disease Control (CDC) and World Health Organization (WHO) recommended against the use of glucocorticoids in patients with COVID-19.10, 11 On day 5, the platelet count recovered to 52 cells/µl with resolution of bleeding. By day 6, platelets were 308 cells/µl, haemoglobin was stable at 76 g/l, and the patient was discharged. Four days after discharge, the patient returned to the hospital with extreme weakness and fatigue, intermittent fever and cough without bleeding. Haemoglobin was 60 g/l with a normal platelet count. Laboratory assessments showed a reticulocyte count of 22%, lactate dehydrogenase (LDH) of 947 u/l, elevated fibrinogen, haptoglobin <20 g/l, and positive direct Coombs test (3+), concerning for new immune-mediated haemolytic anaemia. Peripheral blood smear was notable for microspherocytes, nucleated red blood cells, and reticulocytes (Fig 1). Coupled with his recent history of ITP, his clinical picture raised concern for ES versus immune haemolytic anaemia secondary to IVIG. Once again, corticosteroids were avoided in the setting of COVID-19 infection, and IVIG therapy was re-initiated. Meanwhile, the patient continued to have low-grade fevers with lower extremity weakness and hypoxaemia requiring 2 l of oxygen. After a second dose of IVIG, he developed a left popliteal deep venous thrombosis for which he was started on therapeutic heparin. His haemoglobin eventually stabilised at 70 g/l with a robust reticulocyte response. IVIG was discontinued with concern for its contribution to macrovascular thromboembolism. At 4 weeks after discharge, blood counts showed a haemoglobin level of 110 g/l and 505 platelets/µl. The pathogenesis and management of ES in the setting of the inflammatory milieu of COVID-19 has not been previously described and represents a unique challenge in clinical management. The exact pathophysiology of ES is not fully elucidated, but studies suggest the intersection of autoimmunity and predisposing immune dysregulation is involved. Several proposed mechanisms of autoimmunity have been described, including activation of Bruton tyrosine kinase and overexpression of cytokines.12, 13 Evolving accounts of COVID-19 have reported a pro-inflammatory state with laboratory abnormalities such as elevated D-dimer, LDH, C-reactive protein and ferritin. Case series from China reported higher plasma levels of cytokines in critically ill patients.14 Taken together, dysregulation of the immune system in COVID-19 infection could create favourable conditions for the development of ES. The mainstay therapy for ES is typically immunosuppression, including corticosteroids. However, the routine use of corticosteroids in patients with COVID-19 is not recommended outside another indication such as shock or obstructive lung disease, according to established guidelines from the WHO, CDC and Infectious Disease Society of America 10, 11, 15. The basis of this recommendation is founded on analysis from previous viral outbreaks. Retrospective data from the Middle East Respiratory Syndrome (MERS) outbreak have associated steroid therapy with increased mortality and delayed clearance of viral RNA.10 Meta-analysis of steroid use in Severe Acute Respiratory Syndrome (SARS) has been associated with harm, and systematic review of corticosteroid use in patients with influenza was associated with increased mortality.11 Thus, alternatives to corticosteroids were used to manage our patient with ES. IVIG, both diagnostic and therapeutic in this case, was used to treat our patient's thrombocytopenia. Thrombopoietin receptor agonists could also be considered in this scenario, as combination of these agents may be useful if platelet rebound is insufficient. It is difficult to know if autoimmune haemolytic anaemia in our patient is related to IVIG or underlying immune dysregulation from COVID-19. Nonetheless, treatment options are limited for patients with COVID-19 in this context, and further data are needed to guide the use of immunosuppression in patients with autoimmune complications of SARS coronavirus 2. Based on the case above, we propose a framework for patients with COVID-19 with haematological dysfunction that addresses the acuity of bleeding, avoidance of immunosuppression, and support for both platelet and anaemia components of ES. Until more data emerge on the use of corticosteroids in setting of COVID-19, avoidance of corticosteroids should be considered in autoimmune haematological diseases in patients with COVID-19 in favour of alternative therapies. The authors have no potential conflict of interest to disclose.

Background Submucous cleft palate (SMCP) has a heterogeneous presentation and is often identified late or misdiagnosed. Diagnosis is prompted by speech, resonance or feeding symptoms associated with velopharyngeal insufficiency. However, the broader impacts of SMCP on communication have rarely been examined and therefore are poorly understood. Aim To describe the communicative profile of individuals with non-syndromic SMCP by examining speech, language and pragmatics (social language). Methods & Procedures Fifteen participants with SMCP aged 5;1-12;8, without a genetic diagnosis, participated in the study. Participants completed standardized assessments examining language, resonance, speech and non-verbal intellect. Parents also completed the Children's Communication Checklist (CCC-2), which provided a measure of overall communicative ability, including pragmatic skills. Formal language outcomes were compared with two cohorts: 36 individuals with overt non-syndromic clefts and 129 individuals with no history of clefting. Outcomes & Results Speech intelligibility was reduced secondary to hypernasality, disordered articulation and/or impaired phonology (n = 7) in children with SMCP. Poorer overall language outcomes were observed for children with SMCP compared with both those with overt clefts and no history of clefting (p < 0.001). Language scores for children with SMCP ranged from impaired (n = 6) to above the standardized mean (n = 4). Receptive and expressive language performance were independently correlated with non-verbal IQ (p < 0.01). Those with severe language impairment (n = 4) also had borderline or impaired non-verbal IQ. Parents reported that speech and semantics were the most affected sub-domains of communication, while scores were the highest for the initiation domain. Speech and language skills were correlated strongly with pragmatics (r = 0.877, p < 0.01). Conclusions & Implications Overall, performance was variable within the SMCP group across speech, language and pragmatic assessments. In addition to well-documented speech difficulties, children with SMCP may have language or pragmatic impairments, suggesting that further neurodevelopmental influences may be at play. As such, for individuals with SMCP, additional clinical screening of language and pragmatic abilities may be required to ensure accurate diagnosis and guide both cleft and non-cleft related therapy programmes.

Commentary on: Best K, Bogossian F, New K. Language exposure of preterm infants in the neonatal unit: A systematic review. 2018 Jul 24;114:261-276. https://doi.org/10.1159/000489600. Hospitalised infants have long been known to be physiologically and neurodevelopmentally vulnerable, yet hypothesised risk factors seem to contribute only part of the puzzle 1. Recently, there has been an upsurge in research and commentary questioning whether language exposure during an infant's hospital stay might constitute a significant risk factor for poor outcomes – and thus fertile ground for early intervention. In this systematic review, Best, Bogossian, and New 2 examined observational and intervention studies of language exposure for hospitalised preterm neonates. Ten studies met their inclusion criteria. The authors found evidence that hospitalised preterm infants are exposed, simultaneously, to high levels of noise and low levels of language. Further, intervention studies, though reporting some promising outcomes in the short term, have been limited by heterogeneity and risk of confounding. The timeliness of this review is demonstrated by the contemporaneous publication of more intervention studies in the area of language exposure in the NICU 3, 4, and similarly targeted systematic reviews 5, 6. The authors reflect that the literature is currently limited, given factors mentioned above. Correspondingly, language intervention (as a component of neurodevelopmental care) and speech-language pathology services are not standard in neonatal hospital contexts 7, 8. Yet, if the growing number of publications is any indication, interest is increasing, and a more robust evidence base will soon emerge. Adequately powered, randomized controlled trials using appropriate stimuli will be critical, and, as the authors suggest, longer term follow-up is indicated. The authors suggest ‘2 years’ corrected age and beyond’ 2 as a target for longitudinal studies of intervention outcomes. We emphasise ‘and beyond’, given that language development is notoriously unstable at two years’, and longer term follow-up may be necessary to obtain valid outcomes 9. While awaiting the outcomes of such studies, clinicians may elect to trial strategies that increase language exposure for hospitalised preterm infants, given that the hospital language environment is considerably more impoverished than the in utero language environment at equivalent gestational age, and that the literature seems to suggest some benefit 2, 5, 6. Language exposure is pertinent to everyone who interacts with hospitalised infants, but speech-language pathologists and music therapists are particularly well suited to promote optimal input, and to train parents and staff in how to increase language exposure safely and appropriately. Increasing metrics such as adult word count could be as simple as adopting practices that are already promoted to parents of infants in the community: reading and singing to babies, narrating care tasks etc. Importantly, the infant's response to language exposure should be individually targeted, ensuring the sound level is appropriate, and the infant maintains physiological and neurobehavioural stability. The sensory deprivation experienced by hospitalised preterm infants is increasingly perceived as problematic. Paucity of language exposure is a critical component of this deprivation, but further investigation will be required to determine the relationship between language deprivation and relevant outcomes (especially language development) and to explore whether simple language- and music-based interventions are effective in protecting preterm infants from the effects of an extra-uterine environment. https://ebneo.org/2019/03/language-environment/ National Health and Medical Research Council (Career Development Fellowship 11098714, Centre for Research Excellence in Newborn Medicine grant 1060733), Victorian government Operational Infrastructure Support Program. The authors have no potential conflicts of interest to declare.

Purpose Language difficulties are prevalent among children born preterm. Existing studies have largely used standardized language tests, providing limited scope for detailed descriptive examination of preterm language. This study aimed to examine differences in conversational language between children born < 30 weeks and at term as well as correlations between language sample analysis (LSA) and a standardized language tool. Method Two hundred four 3-year-olds (103 born < 30 weeks, 101 born at term) recruited at birth provided a 10-min language sample and completed the Preschool Language Scales-Fifth Edition (I. Zimmerman, Steiner, & Pond, 2011). LSA was conducted using the Systematic Analysis of Language Transcripts and Index of Productive Syntax. Group differences were analyzed using linear regression, and Pearson correlation coefficient (coef) was used to determine correlations between measures. Results Children born < 30 weeks scored lower than term-born peers on multiple metrics when controlled for confounding factors (sex, high social risk, multilingualism, and diagnosed neurodevelopmental disorders), including mean length of utterance in morphemes (coef = -0.28, 95% confidence interval [CI] [-0.56, 0.01]) and words (coef = -0.29, 95% CI [-0.53, -0.05]), number of different word roots (coef = -10.04, 95% CI [-17.93, -2.14]), and Index of Productive Syntax sentence structures (coef = -1.81, 95% CI [-3.10, -0.52]). Other variables (e.g., number of utterances, number of nouns and adjectives) were not significantly different between groups. LSA and the Preschool Language Scales-Fifth Edition were at most moderately correlated (≤ .45). Conclusions Three-year-old children born preterm demonstrated poorer conversational language than children born at term, with some specific areas of deficit emerging. Furthermore, formal assessment and LSA appear to provide relatively distinct and yet complementary data to guide diagnostic and intervention decisions. Supplemental Material https://doi.org/10.23641/asha.11368073.

Q What is the quality of evidence for speech sound interventions with preschool-aged children?Design: Systematic review (pre-registered with PROSPERO)Data sources: The authors searched 18 databases...

Aim To compare language, speech, and voice of children born preterm and at term, and determine relevant predictors of outcome. Method Three hundred infants (150 males, 150 females; 149 born at <30wks’ gestation, 151 term‐born) were prospectively recruited at birth from the Royal Women's Hospital. We administered the Preschool Language Scales, Fifth Edition, Diagnostic Evaluation of Articulation and Phonology, Grade Roughness Breathiness Asthenia Strain Scale, and Pediatric Voice Handicap Index at 3 years, and compared groups. We examined hypothesized predictors in children born preterm: gestational age at birth, birthweight, sex, chronic lung disease, high social risk, multilingualism, neurodevelopmental diagnosis, and oromotor feeding. Results Children born preterm had poorer language than children born at term (coefficient −5.43). Speech and voice were similar between groups (coefficients −0.70 to 1.63). Chronic lung disease predicted voice (coefficient 6.05); male sex (coefficients 4.54–6.18), high social risk (coefficient −6.02 to −9.30), and neurodevelopmental diagnosis (coefficients −16.42 to −20.61) predicted language. Interpretation Children born before 30 weeks’ gestation had poorer language than children born at term. Children born preterm with neurodevelopmental disabilities or high social risk experience poorer language outcomes, and would benefit from enrichment of their language environment. What this paper adds Speech and voice outcomes were similar between children born preterm and at term. Male sex, high social risk, and neurodevelopmental diagnosis predicted language outcomes.

OBJECTIVES: To examine profiles of infant regulatory behaviors and associated family characteristics in a community sample of 12-month-old infants and mental health difficulties at 5 and 11 years of age. METHODS: Items relating to demographic characteristics, maternal distress, and infant regulation were completed by 1759 mothers when their infants were 8 to 12 months old. The Strengths and Difficulties Questionnaire was completed by mothers at child ages 5 (n = 1002) and 11 (n = 871) years. RESULTS: Analyses revealed 5 profiles ranging from the most settled infants (36.8%) to those with mainly sleep problems (25.4%), isolated mild-to-moderate tantrums (21.3%), complex regulatory difficulties (13.2%), and complex and severe regulatory difficulties (3.4%). Compared with those in the settled profile, children in the moderately unsettled profile were more likely to score in the clinical range for total difficulties at 11 years of age (odds ratio [OR] 2.85; 95% confidence interval [CI]: 1.28 to 6.36; P < .01), and children in the severely unsettled profile were more likely to score in the clinical range at 5 (OR 9.35; 95% CI: 2.49 to 35.11; P < .01) and 11 years of age (OR 10.37; 95% CI: 3.74 to 28.70; P < .01). CONCLUSIONS: Infants with multiple moderate-to-severe regulatory problems experience substantially heightened odds of clinically significant mental health concerns during childhood, and these symptoms appear to worsen over time. Clinicians must inquire about the extent, complexity, and severity of infant regulatory problems to identify those in the most urgent need of intervention and support.

Objective: Subclinical phenotypes of nonsyndromic cleft lip with or without cleft palate (CL ± P) may be identified from clinically “unaffected” relatives and could be associated with specific cleft-related gene mutations. It has been hypothesized that velopharyngeal insufficiency (VPI) may be a subclinical phenotype of interest in this population, but this has not been explored quantitatively with appropriate control cohorts. The aim of this case–control study was to compare VPI in at-risk clinically unaffected relatives of individuals with nonsyndromic CL ± P with a low-risk matched normative Australian cohort. Participants: Clinically unaffected (ie, with no overt cleft) first-degree relatives of a proband with nonsyndromic CL ± P (n = 189) and noncleft controls (n = 207). Main Outcome Measure(s): Perceptual measures of VPI encompassing resonance, nasal emission, and articulation were evaluated using the Great Ormond Street Speech Assessment. Quantitative measures of VPI were obtained from the Nasometer II using standardized adult and pediatric speech stimuli. Results: Both perceptual and instrumental measures showed no significant difference ( P > .01) between the VPI in unaffected relatives and the noncleft comparison group. Mean nasalance scores for both groups were calculated and reported according to speech stimuli, age, and sex. Conclusions: Results suggest that VPI, measured through speech, is not a significant subclinical phenotype of nonsyndromic CL ± P. Therefore, further familial genetic investigations exploring VPI may not yield meaningful results. Exploration across multiple subclinical phenotypes in larger cohorts may enable researchers to better understand the multifaceted nature of this complex and heterogeneous anomaly.

Commentary on: Dane E Anderson & Aniruddh D Patel. Infants born preterm, stress, and neurodevelopmental in the neonatal intensive care unit: might music have an impact? Developmental Medicine & Child Neurology. 2018 Jan 24; ePub ahead of print https://doi.org/10.1111/dmcn.13663. PMID 29363098. The use of music to soothe babies predates written history 1. As more medically vulnerable infants survive, and spend long periods hospitalised, Developmental Care has evolved to optimise neurodevelopment. As part of the emergence of Developmental Care, medical research has reflected a growing interest in the role of music with hospitalised neonates, its effectiveness and the mechanisms by which it may change infant outcomes. Here 2, Anderson and Patel examined studies of musical interventions for hospitalised neonates, excluding reviews and meta-analyses. They chose ten articles that they perceived as methodologically rigorous, and summarised them to ‘highlight the most well-supported data’ 2. Based on these articles, they suggested that music had effects on behavioural and physiological infant metrics, ranging from reduced inconsolable crying to reduced resting energy expenditure. Further, the authors emphasised studies that explored the mechanisms by which music affects behavioural and physiological markers. It should be noted that the strength of the selected evidence varied (e.g. methodologies ranging from within-subject comparison designs to randomised controlled trials [RCTs]) and was not subject to a standardised measure of methodological rigour. A further consideration, as the authors note, is that the examined studies used a range of stimuli, from commercially available recordings to live parent performance. This methodological heterogeneity may have a considerable effect on outcomes. While previous meta-analyses and systematic reviews on this topic exist 3-6, this review took a neurodevelopmental perspective and highlighted only those studies that seemed most rigorous, based on author perception. However, in the absence of a replicable, standardised evaluation of methodological quality, and a systematic approach to study selection, the conclusions must be interpreted cautiously. The authors 2 highlighted pertinent directions for research – uncovering mechanisms by which music affects preterm infants and investigating long-term neurodevelopmental effects of musical interventions. They further emphasised the need for trained music therapists to deliver direct interventions and to avoid overstimulation of the infant. We would add that indirect interventions delivered by music therapists such as training parents to deliver infant-led musical stimulation may provide a safe and culturally responsive intervention and merits further research 7. With recent evidence suggesting that preterm neonates may be suffering from sensory deprivation 8, 9, this review complements previous evidence 3-6 in suggesting that music therapy may moderate the effects of preterm birth on neurodevelopment. However, further investigation through well-designed and adequately powered RCTs, which give appropriate consideration to the nature of the musical stimuli provided, will be essential in establishing the short- and long-term effectiveness and safety of this intervention. https://ebneo.org/2018/05/the-effects-of-music-on-hospitalized-preterm-neonates/ National Health and Medical Research Council (career development grant 607315, Centre for Research Excellence in Child Language grant 1023493; Career Development Fellowship 11098714, Centre for Research Excellence in Newborn Medicine grant 1060733), Australian Government Research Training Program Scholarship, Speech Pathology Australia's Nadia Verrall Memorial Research Grant and Victorian government Operational Infrastructure Support Program. The authors have no potential conflict of interests to declare.

Purpose Language skills are critical. Children born very preterm are vulnerable to language problems, but further work is needed to determine characteristics and specific predictors of language problems in this population. We aimed to compare language outcomes between 2-year-old children born <30 weeks and their term-born peers; and to explore risk factors for language difficulties in this cohort. Design Language at 2 years was examined in 134 children born <30 weeks and 133 children born at term using the Bayley Scales of Infant and Toddler Development - 3rd Edition (Bayley-3) and the Communication and Symbolic Behaviour Scale: Developmental Profile (Infant Toddler Checklist) (CSBS: DP). Outcomes were compared between groups. Factors hypothesised to predict language outcome were examined in the preterm group: gestational age at birth, birth weight z-score, sex, hearing loss, multilingualism, maternal education, brain abnormality on MRI, medical risk and oromotor concerns at 12 months. Results Children born <30 weeks performed more poorly on the CSBS: DP (particularly the social and symbolic composites) and the language scale of the Bayley-3 at 2 years than term-born peers. Lower gestational age at birth, male sex, hearing loss and multilingualism predicted poorer language scores. Conclusions Despite improvements in medical management, children born very preterm exhibit language delays at 2 years of age, with specific deficits in social communication and symbolic skills. Significant predictors of poorer language outcomes were similar to those in the general population (male sex, hearing loss, multilingualism), suggesting that further work is needed to establish which specific factors place preterm-born children at heightened risk.

BACKGROUND:Feeding difficulties threaten growth, health and neurodevelopment, and are prevalent among infants born preterm. The literature differs on (i) whether these problems persist into early childhood, and (ii) risk factors in the preterm population. In this study we explore feeding difficulties and risk factors in preterm and term-born three-year-olds.OBJECTIVES:To determine whether three-year-olds born <30 weeks have poorer feeding outcomes than their term-born peers; and identify predictors of feeding outcomes in children born <30 weeks.METHODS:Feeding outcomes were examined in three-year-old children born <30 weeks, and a term-born comparison group, using parent report and the Behavioral Pediatric Feeding Assessment Scale (BPFAS). Factors hypothesized to be associated with feeding difficulties and preterm birth were examined in the preterm group, including: gestational age at birth, birth weight z-score, chronic lung disease (CLD), nasogastric tube (NGT) feeding at hospital discharge, age at breastfeeding cessation, oromotor feeding impairment at 12 months, weight at 12 months in kilograms and neurodevelopmental diagnoses.RESULTS:In 217 children (111 born <30 weeks, 106 term-born), parents of children born <30 weeks reported more feeding concerns on parent report questions than parents of term-born peers. CLD, NGT at discharge, neurodevelopmental diagnoses and weight at 12 months predicted these parent-reported outcomes. By contrast, there was no difference in BPFAS results between preterm and term groups, and BPFAS scores were predicted only by birth-weight z-score in the preterm group.CONCLUSIONS:Behavioral feeding outcomes for three-year-old children born <30 weeks were equivalent to term-born peers in this study, however parental concerns about feeding differed. Further investigation is required to identify the drivers of parent concerns about feeding. Children displaying core risk factors warrant specific follow-up of feeding outcomes.

Paediatric eating and drinking problems are highly prevalent, and associated with dietary adequacy, growth and parent mental health (1–3). Oral motor skills – coordinated movements of the oral structures that facilitate sucking, biting, chewing and swallowing – are an essential component of oral eating and drinking. Thus, evaluation of oral motor skills in children with eating and drinking problems is critical to delineate specific eating and drinking problems to develop targeted intervention programmes. Yet eating and drinking assessment tools, in particular parent questionnaires, frequently omit information about oral motor skills, focusing instead on the behavioural components of eating and drinking (4). The Child Oral and Motor Proficiency Scale (ChOMPS) fills this gap, providing a validated parent questionnaire that evaluates the motor and oral motor skills underlying eating and drinking ability for children aged from six months to seven years (5). While content validation and further psychometric data are forthcoming, in this issue Pados et al. (5) report the norms for this new tool, derived from an international sample of 1057 healthy, typically developing children across 11 age groupings (six to nine months, 9– 12 months, 12–15 months, 15–18 months, 18–24 months, 24–30 months, 30–36 months, three to four years, four to five years, five to six years and six to seven years). The narrower age grouping among younger children reflects a relatively faster rate of developmental change in feeding abilities. Parents of eligible participants (children aged six months to seven years, being offered solid foods to eat by mouth, without diagnoses of significant developmental or medical issues that may affect feeding, and without feeding problems; parents >18 years, with internet access and English literacy) completed the 63 item questionnaire, answering questions about specific eating and drinking behaviours, and supportive motor skills such as postural control. Answers were allocated two points for ‘yes’, one for ‘sometimes’ and no points for ‘not yet,’ and scores for four subscales (Basic Movement Patterns, Fundamental Oral Motor Skills, Oral-Motor Coordination and Complex Movements Patterns) and a total score were calculated. The authors reported the means, standard deviations, medians, ranges and 5th and 10th percentiles for each age group across the four subscales as well as the total score. The 5th and 10th percentile scores were interpreted as cutoffs, identifying children who require further assessment. The authors highlighted that the ChOMPS can be used in conjunction with their behavioural eating questionnaire, the Pediatric Eating Assessment Tool (PediEAT), to obtain a more complete picture of a child’s eating and drinking. The ChOMPS is a novel development in a field that has lacked an assessment tool of this type. Strengths include its large normative sample, and the consideration of reliability and validity that were clearly intrinsic to its development. The publication of this paper suggests a number of implications for clinical practice, research and future directions. For clinicians, the ChOMPSmay be used inmultiple ways. Primary health care practitioners, such as paediatricians and child health nurses, may find the ChOMPS and/or PediEAT useful to interrogate clinical or parental concerns about eating or drinking, and to help determine whether referral to a specialised feeding therapy service is warranted. This may assist in reducing unnecessary referrals, and facilitate early intervention for children whose presentation warrants it. Given that eating and drinking problems are frequently the earliest clinical signs of more pervasive developmental issues (6), the benefits of obtaining an early referral may extend beyond the feeding domain. Within specialised services, the lack of quantitative measurement tools presents a challenge for outcomemeasurement anddocumentation for insurers or fundingbodies. This situation couldbe improvedvia access to numerical scores using a tool such as the ChOMPS, with its large normative sample and forthcoming psychometric data. In a research context, psychometrically robust tools evaluating eating and drinking ability are sorely needed (4). The ChOMPS may facilitate research exploring oral motor outcomes for a rangeof at-risk clinical populations, including children born preterm, children who have sustained neurologically damage from a stroke or traumatic brain injury, children with craniofacial abnormalities or trauma and children with developmental disabilities. Furthermore, an ongoing problem in developing andmeasuring interventions fororalmotor eating anddrinkingproblemshasbeen the lack of psychometrically robust tools to identify these problems, and track progress. Pending further psychometric data, the ChOMPS could prove useful in these contexts. One limitation of the tool, which Pados et al. (5) acknowledge, is that the families comprising the normative