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Association of Preterm Birth Weight on Developmental Coordination Disorder: A Systematic Review Berube, Michelle; Edwards, Jessica; Erlandson, Kelcey; Haug, Stephanie; Johnstone, Heather; Meagher, Meaghan; Sarkodee-Adoo, Shirley 2010

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  Michelle Berube, Jessica Edwards, Kelcey Erlandson, Stephanie Haug, Heather Johnstone, Meghan Meagher, Shirley Sarkodee-AdooSupervisor: Jill ZwickerPrenatal care, obstetrics, and neonatal medicine care has improved significantly in the past few decades(1)Increased survival rates among infants born preterm (<37 weeks) and low birth weight (LBW; <2,500g)(1)These children are more likely to experience difficulties with growth, learning, behavior and motor development(2,3,4)Deficits include coordination, balance, gross and fine motor control and         visomotor integration(5-8)Confusing terminology(9) ‘clumsy child syndrome’, ‘developmental dyspraxia’ and ‘perceptulmotor dysfunction’ Developmental Coordination Disorder (DCD) was defined in 1994 by the DSM IVAn impairment of motor performance sufficient to produce functional performance deficits not explicable by the child’s age or intellect, or by other diagnosable neurological or psychiatric disorder(10)Difficulties with handwriting, typing, ball skills, skipping, hopping, and a variety of other skills(10)Potential long term implications(6,10)Lack of evidence that shows a relationship between LBW/preterm birth with DCDWhat is the relationship between preterm birth and/or low birth weight, and the occurrence of Developmental Coordination Disorder in school age children?MEDLINE (1950–June 2010)EMBASE (1980–June 2010)CINAHL (1982–June 2010) PsycINFO (1975–June 2010) Educational Resource Information Center (ERIC) (1969–June 2010) PEDro (1929–June 2010) Cochrane Database of Systematic Reviews (1998–June 2010) Final searches completed June 30, 2010ExposureOutcomeInfant, PrematureMotor Skills Disorderspremature infantClumsy child SyndromeprematurityDCDInfant, Low Birth WeightDevelopmental Coordination disorderlow birth weight infantMotor ImpairmentInfant, Very Low Birth WeightMotor Skill Disordervery low birth weightDevelopmental disabilityextremely low birth weight infantAnd 33 additional keywords!Study population was school-age children (age 5-18 years)Study included children exposed to preterm birth (<37weeks) and/or low birth weight (<2,500g) Focus of the study was on motor coordination impairmentsNo comparison groupIncluded children diagnosed with co-morbidities other than ADD or ADHD Did not include a standardized measure of motor impairmentDid not have separate data for school-aged children Focused on children small for gestational ageFocused on medical interventionQualitative in natureNot published in EnglishCitations identified through electronic database search (CINAHL, Chochrane, Embase, ERIC, Medline, PEDro, PsycINFO) (n = 2527)Citations excluded based on inclusion and exclusion criteria (n = 1855)Citations Abstracts put forward for review (n = 268)Full text articles assessed for eligibility (n = 82)Studies included in qualitative synthesis (n = 20)Studies included in meta-analysis (n = 5)Abstracts excluded based on inclusion and exclusion criteria (n = 186)Studies excluded after full text review (n = 62)Not relevant design n = 1No comparison group = 15Comparison group not fully explained n = 5No standardized measure of motor impairment and/or no separate data for school aged children n = 41Citations put forward for review after duplicates removed (n = 2123)Citations identified through electronic database search (CINAHL, Chochrane, Embase, ERIC, Medline, PEDro, PsycINFO) (n = 2527)Citations excluded based on inclusion and exclusion criteria (n = 1855)Citations Abstracts put forward for review (n = 268)Full text articles assessed for eligibility (n = 82)Studies included in qualitative synthesis (n = 20)Studies included in meta-analysis (n = 5)Abstracts excluded based on inclusion and exclusion criteria (n = 186)Studies excluded after full text review (n = 62)Not relevant design n = 1No comparison group = 15Comparison group not fully explained n = 5No standardized measure of motor impairment and/or no separate data for school aged children n = 41Citations put forward for review after duplicates removed (n = 2123)Citations identified through electronic database search (CINAHL, Chochrane, Embase, ERIC, Medline, PEDro, PsycINFO) (n = 2527)Citations excluded based on inclusion and exclusion criteria (n = 1855)Citations Abstracts put forward for review (n = 268)Full text articles assessed for eligibility (n = 82)Studies included in qualitative synthesis (n = 20)Studies included in meta-analysis (n = 5)Abstracts excluded based on inclusion and exclusion criteria (n = 186)Studies excluded after full text review (n = 62)Not relevant design n = 1No comparison group = 15Comparison group not fully explained n = 5No standardized measure of motor impairment and/or no separate data for school aged children n = 41Citations put forward for review after duplicates removed (n = 2123)Citations identified through electronic database search (CINAHL, Chochrane, Embase, ERIC, Medline, PEDro, PsycINFO) (n = 2527)Citations excluded based on inclusion and exclusion criteria (n = 1855)Citations Abstracts put forward for review (n = 268)Full text articles assessed for eligibility (n = 82)Studies included in qualitative synthesis (n = 20)Studies included in meta-analysis (n = 5)Abstracts excluded based on inclusion and exclusion criteria (n = 186)Studies excluded after full text review (n = 62)Not relevant design n = 1No comparison group = 15Comparison group not fully explained n = 5No standardized measure of motor impairment and/or no separate data for school aged children n = 41Citations put forward for review after duplicates removed (n = 2123)Newcastle-Ottawa Quality Assessment ScaleDesigned for non-randomized studiesStudy quality was based on 9 criteria within 3 domainsSelection of study groups (4 criteria)Comparability of study groups (1 criterion)Ascertainment of outcome of interest (3 criteria)A star rating system was applied9 stars totalInformation extracted included: Citation data, purpose, rationale, study designParticipant characteristics and exposureInclusion and exclusion criteriaOutcome measures, results, limitationsOriginal authors were contacted when necessary20 studies were included in descriptive review2 studies used the same data setUsed Review Manager Version 5.0 (22)Odds ratio using the Mantel-Haenszel method with a random effects model of analysisExamined for similarities in outcome measure and study populationSub-group analysis was completed for studies that included only ELBW population20 articles selection (19 unique studies)Study Design11 were case controlled(1,5,6,7,8,11-16)   8 were cohort(2, 4,10,17-21)Age of participantsRanged from 5 – 14 yearsSample Sizes14 -1237Study groups5 studies examined gestational age(7,16,19,20,21)14 studies examined birth weight(1,2,4-6,8,10-15,17,18)Control groupsFull term, NBW, bothOutcome measuresMABC, 3-item MABC, non-standardized MABC, TMI, BOTMP, PDMS, Touwen Exam, MAP16/19 data sets showed a statistically significant difference in outcome measure scores of their study population(1,2, 5-8, 10-17,19,21) The studied population performed worse9/12 data sets demonstrated significantly more children classified as having a motor impairment if born preterm and/or low birth weight(5,6,10,13,17,19,21)1/19 data sets reported a non-significant difference in motor competency between children born preterm and term(20)Goyen and Lui (2008)Prevalence of DCD was 42% in the preterm/ELBW population versus 8% in control group (p = 0.0001) 30% of study group had severe DCD (defined as scores < 5th percentile) Holsti et al. (2002) 51% of the study group were classified as having DCD (scores < 1 SD) versus 5% in control group       (p < 0.0001)5 studies included(5,6,10,13,17)Examined the effect of VLBW (1,500g or less) on motor impairment using the MABC2 meta-analyses(22)Used the criteria of children scoring below the 5th percentileUsed the criteria of children scoring below the 15th percentileBoth analyses showed a significant increase         p <0.00001, p <0.0001) in the likelihood of motor impairment in VLBW childrenFirst systematic review of the literaturePreterm/LBW children scored lower on motor competency measuresPreterm/LBW children higher prevalence of motor impairment≤ 5th percentile on the MABC:VLBW children are 8.11 times more likely than NBW controls to score below the 5th percentile on this motor test≤ 15th percentile on the MABC:VLBW children are 11.30 times more likely than NBW controls to score below the 15th percentile on this motor testConference that defined the most important factors of diagnosis, assessment and intervention of DCDDocumented cut-off criteria5th percentile of motor competency testVLBW children are more likely to score below the 15th percentile than the 5th percentile on the MABCStudyNumber of StarsDavis et al. (2007)9 /9Goyen & Lui (2009)8 /9Evensen et al. (2004) 8 /9Burns et al. (2008)7 /9Powls et al. (1995)7 /9Forslund (1992) reported a non-significant difference in motor competencyOlder gestational age (<35 weeks)Compensatory movementsAmbidextrousde Kieviet et al. (2009) demonstrated motor impairment in very preterm and VLBW children(24)We demonstrate a link between motor impairments and the occurrence of DCD in VLBW childrenPreterm/VLBW children continue to experience motor problems throughout school years(5, 2,13,19)Motor problems increase when children reach school age(24)Children withdraw from participation with peersLack of consistency surrounding appropriate cut-off criteria by which to diagnose DCDProblem for children with minor motor impairments Need for awareness amongst parents, teachers and health care practitioners regarding DCD5th and 15th percentile cut-off criteria on the MABC can be used to identify DCDOur review demonstrates:Importance of early motor skill assessment Need for early intervention strategiesBiases in the original reviewed articlesDifficulty with blind assessmentsLack of randomization selecting control participantsNOQ Assessment Scale was used to compensate for these biasesClassification of DCDDSM-IV classification established in 1994Excluded non-English studiesExcluded gray literature and articles in publicationA relationship between preterm birth and/or LBW and the development of motor impairment existsObservational analysis demonstrates a statistically significant decrease in motor competency in preterm/LBW childrenIncrease prevalence of motor impairmentMeta-analysis shows that children born preterm or VLBW are significantly more likely to score below the 5th and 15th percentile on the MABCIndicates motor impairment consistent with DCDLeeds Consensus(23)Future research should include:Systematic review of the literature and a meta-analysis which focus on articles that use the DSM-IV criteria of DCDFuture DirectionsNeed for early intervention strategiesNeed for consistent assessment protocols and tools to identify DCDAssessment tools should be available to all professionals working with childrenThe earlier at risk children can be identified the higher the chances they have at a successful interventionLiterature shows a need for early intervention strategiesMany motor impairments are not evident until school-aged yearsImpactShowcase importance of early identification of DCDIncrease general awarenessImprove long-term outcomes for this populationDr. Jill ZwickerMarc RoigCharlotte  BeckDean GiustiniDr. Darlene ReidDr. Elizabeth DeanThank you!Keller H, Ayub BV, Saigal S, Bar-Or O. Neuromotor ability in 5- to 7-year-old children with very low or extremely low birthweight. Dev.Med.Child Neurol. 1998 Oct;40(10):661-666.Holsti L, Grunau RV, Whitfield MF. Developmental coordination disorder in extremely low birth weight children at nine years. J.Dev.Behav.Pediatr. 2002 Feb;23(1):9-15. Zwicker JG, Harris SR.  Quality of Life of Formerly Preterm and Very Low Birth Weight Infants From Preschool Age to Adulthood: A Systematic Review. Pediatr. 2008;121(2):366-376. Hall A, McLeod A, Counsell C, Thomson L, Mutch L. School attainment, cognitive ability and motor function in a total Scottish very-low-birthweight population at eight years: a controlled study. Dev.Med.Child Neurol. 1995 Dec;37(12):1037-1050.Goyen TA, Lui K. Developmental coordination disorder in "apparently normal" schoolchildren born extremely preterm. Arch.Dis.Child. 2009 Apr;94(4):298-302.Burns YR, Danks M, O'Callaghan M, Gray PH, Cooper D, Poulsen L, et al. Motor coordination difficulties and physical fitness of extremely-low-birthweight children. Dev.Med.Child Neurol. 2009 02;51(2):136-142. Lee SY, Chow CB, Ma PY, Ho YB, Shek CC. Gross motor skills of premature, very low-birthweight Chinese children. Ann.Trop.Paediatr. 2004 Jun;24(2):179-183. Leosdottir T, Egilson ST, Georgsdottir I. Performance on extremely low birthweight children at 5 years of age on the Miller Assessment for Preschoolers. Phys.Occup.Ther.Pediatr. 2005;25(4):59-72. Henderson SE, Henderson L. Toward An Understanding of Developmental Coordination Disorder: Terminological and Diagnostic Issues. Neural Plast. 2003;10(1-2):1-13.Davis NM, Ford GW, Anderson PJ, Doyle LW. Developmental coordination disorder at 8 years of age in a regional cohort of extremely-lowbirthweight or very preterm infants. Developmental Medicine & Child Neurology 2007 05;49(5):325-330.Marlow N, Roberts BL, Cooke RW. Motor skills in extremely low birthweight children at the age of 6 years. Arch.Dis.Child. 1989 Jun;64(6):839-847.Marlow N, Roberts L, Cooke R. Outcome at 8 years for children with birth weights of 1250 g or less. Arch.Dis.Child. 1993 Mar;68(3 Spec No):286-290Powls A, Botting N, Cooke RW, Marlow N. Motor impairment in children 12 to 13 years old with a birthweight of less than 1250 g. Arch.Dis.Child.Fetal Neonatal Ed. 1995 Sep;73(2):F62-6.Taylor HG, Klein N, Minich NM, Hack M. Middle-school-age outcomes in children with very low birthweight. Child Dev. 2000 Nov-Dec;71(6):1495-1511.Whitfield MF, Grunau RV, Holsti L. Extremely premature (< or = 800 g) schoolchildren: multiple areas of hidden disability. Arch.Dis.Child.Fetal Neonatal Ed. 1997 Sep;77(2):F85-90.Marlow N, Hennessy EM, Bracewell MA, Wolke D. Motor and executive function at 6 years of age after extremely preterm birth. Pediatrics 2007 10;120(4):793-804.Evensen KA, Vik T, Helbostad J, Indredavik MS, Kulseng S, Brubakk AM. Motor skills in adolescents with low birth weight. Arch.Dis.Child.Fetal Neonatal Ed. 2004 Sep;89(5):F451-5. Roberts BL, Marlow N, Cooke RW. Motor problems among children of very low birthweight. British Journal of Occupational Therapy 1989 03;52(3):97-99. Arnaud C, Daubisse-Marliac L, White-Koning M, Pierrat V, Larroque B, Grandjean H, et al. Prevalence and associated factors of minor neuromotor dysfunctions at age 5 years in prematurely born children: the EPIPAGE Study. Arch.Pediatr.Adolesc.Med. 2007 11;161(11):1053-1061.Forslund M. Growth and motor performance in preterm children at 8 years of age. Acta Paediatr. 1992 Oct;81(10):840-842.Foulder-Hughes L, Cooke R. Do mainstream schoolchildren who were born preterm have motor problems? BR J OCCUP THER 2003;66(1):9-16The Cochrane Collaboration. Cochrane Handbook for Systematic Reviews of Interventions, Review Manager 5.0. 2008;5.0.Sugden D, Chambers M, Utley A, editors. Leeds Consensus Statement. Developmental Coordination Disorder as a Specific Learning Disability; 2004-2005; Leeds, UK: The Economic Science Research Council; 2006.de Kieviet JF, Piek JP, Aarnoudse-Moens CS, Oosterlaan J.  Motor Development in Very Preterm and Very Low-Birth-Weight Children From Birth to Adolescence: A Meta-analysis. JAMA 2009;302(20):2235-2242. Performance in daily activities that requires motor coordination is substantially below that expected, given the person’s chronological age and measure of intelligence. This may be manifested by marked delays in achieving motor milestones (walking, crawling, and sitting), dropping things, ‘‘clumsiness,’’ poor performance in sports, or poor handwriting.The disturbance in Criterion A significantly interferes with academic achievement or activities of daily living.The disturbance is not due to a general medical condition (e.g., cerebral palsy, hemiplegia, or muscular dystrophy) and does not meet the criteria for a pervasive developmental disorder (PDD).If mental retardation is present, the motor difficulties are in excess of those associated with it.1. Infant, Premature/9. very low birth weight.ti,ab.17. clums*.ti,ab.2. premature infant*.ti,ab.10. extremely low birth weight infant*.ti,ab.18. inco?ordinat*.ti,ab.3. prematurity.ti,ab.11. 1 or 2 or 3 or 4 or 5 or 6 or 7 or 8 or 9 or 1019. "perceptuo?motor dysfunction".ti,ab.4. Infant, Low Birth Weight/12. Motor Skills Disorders/20. "perceptual motor difficult*".ti,ab.5. low birth weight infant*.ti,ab.13. motor skill* disorder*.ti,ab.21. "specific development* disorder* of motor function*".ti,ab.6. low birth weight.ti,ab.14. "developmental co?ordination disorder".ti,ab.22. dyspraxi*.ti,ab.7. Infant, Very Low Birth Weight/15. DCD.ti,ab.23. dysgraphi*.ti,ab.8. very low birth weight infant*.ti,ab.16. "clumsy child syndrotme".i,ab.24. "development* dyspraxi*".ti,ab.25. "deficits in attention, motor control, and perception".ti,ab.33. "minor neuro* dysfunction*".ti,ab.41. "motor skills".ti,ab.26. "psychomotor disorder*".ti,ab.34. "minimal brain dysfunction*".ti,ab.42. Developmental Disabilities/27. "sensorimotor difficult*".ti,ab.35. "development* apra*".ti,ab.43. "development* disabilit*".ti,ab.28. "sensory integrat* dysfunction*".ti,ab.36. "physical* awkward*".ti,ab.44. "development* delay disorder*".ti,ab.29. "sensory integrat*".ti,ab.37. "motor impair*".ti,ab.45. child development disorder*.ti,ab.30. "nonverbal learn* disabilit*".ti,ab.38. "motor delay*".ti,ab.46. 33 or 32 or 21 or 26 or 17 or 18 or 30 or 16 or 44 or 25 or 27 or 28 or 40 or 14 or 20 or 24 or 31 or 35 or 22 or 42 or 13 or 23 or 29 or 39 or 36 or 12 or 41 or 15 or 38 or 34 or 45 or 37 or 19 or 4331. "mov* disorder*".ti,ab.39. "motor learn* disabilit*".ti,ab.47. 11 and 4632. "development* right hemisphere syndrome".ti,ab.40. Motor Skills/NEWCASTLE - OTTAWA QUALITY ASSESSMENT SCALECOHORT STUDIESNote: A study can be awarded a maximum of one star for each numbered item within the Selection and Outcome categories. A maximum of two stars can be given for ComparabilitySelection1) Representativeness of the exposed cohorta) truly representative a school-aged child (5-18 years old) born prematurely (<37 weeks) or with low birth weight (<2500 g) in the community *b) somewhat representative of of a school-aged child (5-18 years old) born prematurely (<37 weeks) or with low birth weight (<2500 g) in the community *c) selected group of users eg nursesd) no description of the derivation of the cohort2) Selection of the non exposed cohorta) drawn from the same community as the exposed cohort *b) drawn from a different sourcec) no description of the derivation of the non exposed cohort	3) Ascertainment of exposurea) secure record (eg birth record) *b) structured interview *c) written self reportd) no description4) Demonstration that outcome of interest was not present at start of studya) yes *b) noComparability1) Comparability of cohorts on the basis of the design or analysisa) study controls for co-morbidities *b) study controls for any additional factor: low IQ *	Outcome1) Assessment of outcome a) independent blind assessment *b) record linkage *c) self report	d) no description2) Was follow-up long enough for outcomes to occura) yes (select an adequate follow up period for outcome of interest) *b) No3) Adequacy of follow up of cohortsa) complete follow up - all subjects accounted for *b) subjects lost to follow up unlikely to introduce bias - small number lost (> 20 % ) *c) follow up rate < 80 % and no description of those lostd) no statementStudyTotal Stars ( /9)Selection ( /4)Comparability(/2)Outcome  (/3)Arnaud et al 9423Davis et al 9423Evensen et al8323Goyen & Lui 8422Holsti et al8422Keller et al 8413Lee et al 8422Marlow et al 19898422Marlow et al 19938422Marlow et al 20078413StudyTotal Stars ( /9)Selection ( /4)Comparability (/2)Outcome  (/3)Burns et al 7313Foulder-Hughes & Cooke7412Hall et al7322Leosdottir et al7412Powls et al 7412Roberts et al 7412Taylor et al 7313Whitfield et al 7322StudyStudy DesignExperimental Group(s)Control GroupMotor OutcomeNAge Range or Mean(SD or range)NAge Range or Mean(SD or range)VLBW & ELBW STUDY GROUPSBurns et al.Case-control54 ELBW (<1000g)12 y 6 mo (8 mo) 55 Term12 y 5 mo (8 mo)MABCEvensen et al.Cohort54 VLBW (<1500g)14.1 (0.3) y 83 NGA & Term14.2 (0.3) yMABCHall et al.Cohort45 ELBW (<1000g)8.8 (0.3) y90 NBW8.7 (0.4) yMABCaHolsti et al. Cohort73 ELBW (<801g)8.8 (7.3-11.6) y 18 Term9.3 (9-10) yBOTMPTABLE 1       Description of Studies continuedStudyStudy DesignExperimental Group(s)Control GroupMotor OutcomeNAge Range or Mean(SD or range)NAge Range or Mean(SD or range)Keller et al.	Case-Control14 ELBW (500g-999g), 20 VLBW (1000g-1499g)6.4 y, 6.7 y 24 NBW (>2500g)6.4 yCoordination testb Leosdottir et al.Case-Control32 ELBW (<1000g)5.3 – 5.7 y 55 NBW5.3 – 5.6 yMAPMarlow et al.  1989Case-Control53 ELBW (<1251g)Median (quartile) 73 mo (72-75) 53 NBW73 mo (72-72.5)TMIMarlow et al. 1993Case-Control51 ELBW (<1251g)96 (85-117) mo59 NBW(81-106) moTMIPowls et al.Case-Control47 VLBW (<1250g)12-13 y60 NBW12-13 yMABC TABLE 1       Description of Studies continuedStudyStudy DesignExperimental Group(s)Control GroupMotor OutcomeNAge Range or Mean(SD or range)NAge Range or Mean(SD or range)Roberts et al.Cohort53 ELBW (<1251g)6 y53 Term6 yTMITaylor et al.Case-control60 ELBW (<750g)11 (1.1) y 55 VLBW (750-1499g); 49 NBW11.1 (1.3) y; 11.2 (1.2) yBOTMPWhitfield et al.Case-control90 ELBW (<801g)8.6 y  50 Term9 (6.5-12.1) yBOTMPVLBW/ELBW AND/OR PRETERM STUDY GROUPSDavis et al. Cohort255 ELBW (<1000g) or <28 wk8 y 8 mo (4 mo)208 NBW (>2.499kg)8 y 10 mo (5 mo)MABCTABLE 1       Description of Studies continuedStudyStudy DesignExperimental Group(s)Control GroupMotor OutcomeNAge Range or Mean(SD or range)NAge Range or Mean(SD or range)Goyen & LuiCase-control50 ELBW (<1000g) or <29wk8.8 (0.3) y50 NBW & Term8.8 (0.4) yMABCLee et al.Case-control42 Preterm (<37wk) and VLBW (<1500g)71 (6.8) mo 69 NBW72 (6.5) moPDMSPRETERM STUDY GROUPArnaud et al.Cohort1237 Very Preterm (<33 wk) 5.1 (0.2) y195 Preterm (33-34 wks)287 Term    8.8 (0.4) yTouwen Examc TABLE 1       Description of Studies continuedStudyStudy DesignExperimental Group(s)Control GroupMotor OutcomeNAge Range or Mean(SD or range)NAge Range or Mean(SD or range)ForslundCohort41 Preterm(<35 wk)8.4 y 24 NGA & Term8.2 yTMIFoulder-Hughes & CookeCohort280 Preterm (<32 wk)89.8 (82-101) mo 210 Term89.9 (72-107) moMABCMarlow et al. 2007Case-control180  very preterm (<26 wk) 6.33 (5.17-7.25) y 158 Term6.17 (5.08-7.18) yMABCd Over the past few decades, improvements in prenatal care, obstetrics, and neonatal medicine have resulted in increased survival rates among infants born preterm (<37 weeks), and low birth weight (LBW; <2500g). Despite improvements in short term outcomes however, there remains an increasing concern about the long term outcomes of this population (1380). Research has indicated that infants born preterm or LBW, especially those born very low birth weight (VLBW; <1500g) or extremely low birth weight (ELBW; <1000g), are more likely to experience difficulties with growth, learning, behaviour and motor development, which may persist through to adulthood (1495; Zwicker & Harris, 2008; Hall et al, 1995) State this*Deficits in coordination, balance (Goyen & Lui, 2008; Burns, 2008), gross and fine motor control (1389), and visuomotor integration (1318), which occur in the absence of major motor, sensory, or intellectual disability, are far more prevalent in this population (Davis, 2007). In previous years this condition was given a variety of overlapping labels, including ‘clumsy child syndrome,’ ‘developmental dyspraxia,’ and ‘perceptulmotor dysfunction’ (Henderson & Henderson, 2003 – Terminology and Diagnostic Issues), as no umbrella term to classify this wide spectrum of disorders existed.There was no single disorder or label to properly categorize these children, until in 1994 the DSM IV published a definition of Developmental Coordination Disorder (DCD)*In 1994, a diagnostic category was developed that would properly label this group of children (ID 1459). The term Developmental Coordination Disorder (DCD), from the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), is now widely used to categorize children with minor motor difficulties within a pediatric population, including those who were born prematurely or LBW (ID 1459). DCD is currently defined as (ID 1459 #12):Performance in daily activities that requires motor coordination is substantially below that expected, given the person’s chronological age and measure of intelligence. This may be manifested by marked delays in achieving motor milestones (walking, crawling, and sitting), dropping things, ‘‘clumsiness,’’ poor performance in sports, or poor handwriting.The disturbance in Criterion A significantly interferes with academic achievement or activities of daily living.The disturbance is not due to a general medical condition (e.g., cerebral palsy, hemiplegia, or muscular dystrophy) and does not meet the criteria for a pervasive developmental disorder (PDD).If mental retardation is present, the motor difficulties are in excess of those associated with it.*Children with DCD have difficulty with handwriting, typing, ball skills, skipping, hopping, and a variety of other skills which are integral to participation in school (14). These impairments can in turn influence their ability to participate in classroom activities, and interact with peers. Low self esteem, social and emotional isolation, and poor physical fitness are all potential long term implications (Davis, 2007, Burns, 2008). There is a need in the literature to more firmly document this relationship. This will allow for early identification and intervention strategies to be put in place target these children, and improve the long term outcomes. The aim of this systematic review was to answer the question: what is the relationship between preterm birth and/or low birth weight, and the occurrence of Developmental Coordination Disorder in school age children?**Two independent reviewers for each process*Two independent reviewers for each process*Two independent reviewers for each process*Two independent reviewers for each process*Two independent reviewers for each process*The methodologic quality of each study was assessed using the Newcastle-Ottawa Assessment Scale, which was designed for non-randomized studies. Study quality was based on nine criteria found within three key domains: selection of study groups (four criteria), comparability of study groups (one criterion), and ascertainment of the outcome of interest (three criteria). A star rating system was applied such that each study could receive a maximum of nine stars; a maximum of one star could be awarded for each numbered item within the selection and outcome categories and a maximum of two stars could be awarded for the comparability category. Scores of ______ were considered strong studies, _____ moderate and _____ weak. Study quality was independently assessed by two authors (SH and SSA) and any differences were resolved by a third reviewer (HJ). Quality rating of the included studies may be found in Table ______. Study quality was assessed by two independent reviewers and discrepancies were resolved by a third reviewer*Two authors (JE and MM) independently extracted data from the final 20 articles. The information extracted included: citation data, purpose, rationale, study design, participant characteristics and exposure, inclusion and exclusion criteria, outcome measures, results, limitations, and conclusions. When necessary, the original authors were contacted to provide additional data. All 20 studies selected have been included in the descriptive review and 5 studies which evaluated VLBW children using the MABC were included in the meta-analysis. Table 1 displays summary data from the 20 articles included.*Statistical analysis was undertaken using Review Manager Version 5.0 (Copenhagen: The Nordic Cochrane Centre, The Cochrane Collaboration, 2008) for Mac OS X software. The principal summary measure used was an odds ratio analysis using the Mantel-Haenszel method with a random effects model of analysis.  The random effects model was used because it takes into account the presence of statistical heterogeneity between studies, which is common within this topic of research (** reference), and gives a more conservative estimate of pooled results (Cochrane Handbook for Systematic Reviews of Interventions, Review Manager 5.0, The Cochrane Collaboration, 2008). Studies were examined for homogeneity based on similarities in outcome measure and study population. Where possible, a sub-group analysis (pre-prescribed) was done for those studies which included only an ELBW population.  Pooled results and sub-group analysis results were then presented with corresponding 95% confidence intervals (CI).**Two studies specifically classified children with and without DCD. Goyen and Lui (date), found that a considerable number of apparently normal extremely preterm/ELBW children continued to have motor-based problems into their school years (Goyen and Lui). **Analysis of scores < 5th percentileThe final meta-analytic sample included 460 VLBW children and 456 control children. For children scoring below the 5th percentile, the overall odds ratio was 8.11In a pre-specified subgroup analysis, it appears there are only minor differences in overall effect for children born ELBW and children born VLBW. In the ELBW sub group, which comprised 66.1% of data, the subtotal odds ratio was 7.81 compared to 9.11 in the VLBW sub group. In this analysis of VLBW using the MABC outcome scores <5th percentile, there was overall consistency among studies (no heterogeneity; I2=0%). Analysis of scores < 5th percentileThe final meta-analytic sample included 460 VLBW children and 456 control children. For children scoring below the 5th percentile, the overall odds ratio was 8.11In a pre-specified subgroup analysis, it appears there are only minor differences in overall effect for children born ELBW and children born VLBW. In the ELBW sub group, which comprised 66.1% of data, the subtotal odds ratio was 7.81 compared to 9.11 in the VLBW sub group. In this analysis of VLBW using the MABC outcome scores <5th percentile, there was overall consistency among studies (no heterogeneity; I2=0%). Analysis of scores < 15th percentileUsing a cut-off score of <15th percentile increased the overall odds ratio to 11.30A sub-group analysis was not possible because only one study in this comparison looked at only the VLBW population. However, using this broader criteria for cut-off, there was a high degree of heterogeneity among the studies using (I2=82%). While some studies have highlighted the prevalence of DCD in the preterm population (Goyen & Lui, Holsti et al.), to our knowledge, this is the first systematic review of the literature to examine the association of preterm birth and VLBW/ELBW and DCD. We have also shown that children born prematurely or below 1500g are at greater risk of DCD than their full term or NBW peers. This relationship has been supported by the quantitative data produced by our meta-analyses. *As mentioned previously, two meta-analyses were performed due to differing cut-off criteria on motor assessments used for identification of DCD (Davis et al., 2007). The first meta-analysis demonstrated that VLBW children are 8.11 times more likely than normal birth weight (NBW) controls to score below the 5th percentile on the MABC. The second meta-analysis, showed that VLBW children are 11.30 times more likely than NBW controls to score below the 15th percentile. Although our data suggests that VLBW children are more likely to score below the 15th percentile than the 5th percentile on the MABC, the Leeds Consensus Statement (2006) discusses the practicality of using scores below the 5th percentile instead of the 15th percentile on the MABC based on customary practice in clinics and research studies. Both meta-analyses were statistically significant, however the second meta-analysis displayed a greater amount of heterogeneity in the results. The I2 variable shown in the second forest plot (Figure __) was 82%, indicating that 82% of the difference found in the results was due to differences between the studies. In contrast, the first meta-analysis did not display any heterogeneity. This suggests that all of the outcome measures used in the studies were consistent, and any variation in the results was due to chance, not because of differences between the studies……I am not sure if we need this paragraph, but “hang on to it” just in case*Out of the five studies included in the meta-analyses, Davis et al. (2007) demonstrated the highest methodologic quality, achieving 9 stars out of a possible 9 stars. Goyen & Lui (2009) and Evensen et al. (2004) also displayed high methodologic quality, with each study achieving 8 stars. Seven stars were awarded to Burns et al. (2008) and Powls et al. (1995). Please refer to Table ____ for a summary of the number of stars awarded to each study for the three categories “Selection”, “Comparability” and “Outcome”.*The observational analysis demonstrated that 16 of the 19 included articles displayed significantly lower motor competency scores in the preterm/LBW children when compared with controls. The sole study that reported a non-significant difference in motor competency between children born preterm and term (Forslund, 1992), may be explained due to an older gestational age (<35 weeks) of the preterm infants when compared with the age of preterm groups in other studies. Although the results were not statistically significant, Forslund (1992) reported that the preterm children manifested more compensatory movements in the arms and trunk when performing the balance tasks than term children, and many children (17%) were ambidextrous, a common finding among children with minor motor disorders (Rasmusson et al., 1983). *A meta-analysis conducted by de Keviet et al. (2009) corroborates these findings by demonstrating evidence for substantial motor impairment in very preterm and VLBW children from infancy to 15 years of age. Although the research presented by de Keviet et al. (2009) provides support for our findings, this meta-analysis contained flaws that have been controlled for in the present systematic review, such as lack of control groups in a portion of the studies and inclusion of children with neurological disorders in the study groups. The present systematic review further adds to the literature by demonstrating the link between motor impairments and the occurrence of DCD. *Furthermore, a large body of literature indicates that a considerable proportion of preterm/VLBW children continue to experience motor problems throughout school years (Goyen & Lui, 2008 and Holsti et al., 2002 and Powls et al., 1995 and Arnaud et al., 2007). This systematic review highlights the increased occurrence of motor impairments present in preterm and VLBW children and the persistence of subsequent motor impairment into adolescence. Subtle motor problems are likely to increase when these children reach elementary school age and greater demands are placed on them by school curriculum (de Keviet et al., 2009). In addition, motor impairments may lead susceptible children to withdraw from participation with peers, both socially, and during physical education classes. This has the potential to impact the long term health of this population, and predispose them to developing social and emotional problems later in life (Davis, 2007). *The lack of consistency in the literature surrounding appropriate cut-off criteria by which to diagnose DCD is problematic as children with minor motor impairments may be missed, and will therefore continue to experience motor challenges throughout later school years. This highlights the importance of being able to diagnose DCD to increase awareness amongst parents, teachers and health care practitioners about this disorder in an attempt to prevent some of the long term consequences associated with DCD. *Our data has specifically examined the cut-off criteria for the diagnosis of DCD and has shown that both the 5th and 15th percentile cut-off criteria on the MABC can be used to identify DCD. The present review demonstrates the clinical importance of an early motor skill assessment and the need for implementing intervention strategies that address motor skill impairments in children with DCD before they reach school age.*It is important to note that several limitations exist in this review. Biases and limitations present in the original reviewed articles were subsequently carried forward. For instance, many studies attempted to use independent blind examiners but due to obvious physical differences between the study and control populations it was difficult to have examiners that were truly blind. In addition, many of the studies neglected to randomize the selection of control participants, and these children were instead chosen from the study participants' classes, or groups of friends. To compensate for the presence of bias in the original articles, the Newcastle-Ottawa Quality (NOQ) Assessment Scale was used. The NOQ scale was chosen based on established reliability, and validity, however, this scale does not attach a value to the number of stars awarded to each article. Therefore, one cannot describe the quality of an article as being strong, moderate or weak.*A further limitation to this systematic review is the inclusion of articles written prior to 1994. The DSM-IV classification was established in 1994; prior to this time there was no consistent criterion to classify children with DCD. We have included several articles looking at motor impairments which were published prior to the DSM-IV DCD classification. As a result there was no consistency in the classification of children with motor impairment, which contributes to heterogeneity between some of the reviewed articles. Lastly, this review only included published, peer reviewed articles; gray literature, papers in publication, and non-English sources were excluded. For that reason, it is possible that emerging research on children with DCD may have been excluded.*This systematic review further solidifies the existence of a relationship between preterm birth and/or LBW, and the development of motor impairment. Children born prematurely, or below 1500g, are at a significantly greater risk of developing motor impairments than term born peers. To build upon existing research in this area, we have specifically documented these results using the numerical criteria outlined by the Leeds Consensus for the diagnosis of DCD. *This meta-analysis clearly demonstrates that children born preterm or VLBW are significantly more likely to score below the 5th and 15th percentile on the MABC, which would indicate motor impairment consistent with DCD. Similarly, the observational data provided in this review supports the quantitative findings by demonstrating statistically significant motor impairments in preterm/LBW children.*Future research should include a systematic review of the literature, and ideally a meta-analysis which focus on articles that use the DSM-IV criteria of DCD. Through the review of articles that use only these criteria the relationship between DCD and preterm birth and/or LBW can be further strengthened. With a greater understanding of this relationship comes the need to establish early intervention strategies and consistent assessment protocols. Currently, no consistent assessment tool exists creating inconsistency in the identification and treatment of children with DCD. Such an assessment tool should be made available to all professionals working with children, bridging the gap between research initiatives and clinical practice. The hope is that our research will highlight the importance of early identification of children with DCD, and improve general awareness amongst parents, teachers and clinicians. This will allow for the implementation of intervention strategies targeted at improving the long term outcomes of this population.*The earlier at risk children can be identified the higher the chances they have at a successful intervention. Literature is consistently showing the need for early intervention strategies for these children in order to prevent motor difficulties associated with DCD persisting into adolescent years. Many of the motor impairments associated with DCD are not evident until children reach their school-aged years. This affects their ability to participate in the classroom. However, many teachers are unaware of the term DCD and its implications on school performance and social interaction. The hope is that our research will highlight the importance of early identification of children with DCD, and improve general awareness amongst parents, teachers and clinicians. This will allow for the implementation of intervention strategies targeted at improving the long term outcomes of this population.*Powls used to be number 12*In 1994, a diagnostic category was developed that would properly label this group of children (ID 1459). The term Developmental Coordination Disorder (DCD), from the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), is now widely used to categorize children with minor motor difficulties within a pediatric population, including those who were born prematurely or LBW (ID 1459). DCD is currently defined as (ID 1459 #12):Performance in daily activities that requires motor coordination is substantially below that expected, given the person’s chronological age and measure of intelligence. This may be manifested by marked delays in achieving motor milestones (walking, crawling, and sitting), dropping things, ‘‘clumsiness,’’ poor performance in sports, or poor handwriting.The disturbance in Criterion A significantly interferes with academic achievement or activities of daily living.The disturbance is not due to a general medical condition (e.g., cerebral palsy, hemiplegia, or muscular dystrophy) and does not meet the criteria for a pervasive developmental disorder (PDD).If mental retardation is present, the motor difficulties are in excess of those associated with it.*48. limit 47 to (english language and humans and ("preschool child (2 to 5 years)" or "child (6 to 12 years)" or "adolescent (13 to 18 years)"))49. limit 48 to yr="2009 -Current"**

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