is appropriate for age and the basal ganglia structures are unremarkable. In other planes (not seen in these images), punctate white matter lesions are seen. GMH, germinal matrix haemorrhage. Sciences Library. Protected by copyright. on May 17, 2021 at CU Anschutz Strauss Health http://fn.bmj.com/ Arch Dis Child Fetal Neonatal Ed: first published as 10.1136/archdischild-2020-319450 on 10 May 2021. Downloaded from Soni R, et al. Arch Dis Child Fetal Neonatal Ed 2021;0:F1–F8. doi:10.1136/archdischild-2020-319450 F5 Review Speech and language Language development is seen to be more delayed than motor or cognitive abilities in early childhood. Expressive language, receptive language processing and articulation difficulties with deficits in phonological memory are seen at an older age.33 Academic achievements Preterm children are 2.85 times more likely than their term-born peers to receive special education and score significantly worse in arithmetic, reading and spelling. Weaknesses in attention, executive functioning, visual–motor skills and verbal memory in preterm children may all be contributing factors. Socioeconomic status is an important modifier of the relationship between prematurity and IQ.33 37 STRATEGIES TO IMPROVE OUTCOMES, AND THE CRITICAL ROLE OF FAMILY-CENTRED AND DEVELOPMENTAL CARE Medical therapies Optimising outcomes for premature babies starts with good obstetric care to promote fetal growth and well-being. Use of antenatal corticosteroids and magnesium sulfate is recommended for fetal neuroprotection. Attention to detail with appropriate expertise and facilities at delivery and in everyday management are essential for healthy brain development. Caffeine, used for apnoea of prematurity, is neuroprotective in preclinical models39 and improves survival without neurodevelopmental disability.40 Delayed cord clamping may allow improved cardiovascular transition with improved cerebral autoregulation but meta-analysis failed to demonstrate a significant benefit in major neonatal neurological morbidities.41 Researchers around the world are keenly focused on developing pharmacological therapies to protect the preterm brain. Disappointingly, even though erythropoietin showed neuroprotective effects in preclinical models,42 high-dose early erythropoietin administration to extremely preterm infants did not lower the risk of severe neurodevelopmental impairment or death at 2 years of age.43 Stem cell or exosomal therapies are particularly promising for protection, regeneration and repair of the injured developing brain. Mesenchymal stem cells (MSCs) are attractive because of their low immunogenicity, self-renewing capacity, multilineage differentiation and secretome. Animal models suggest that administration of MSCs significantly reduces brain injury and posthaemorrhagic hydrocephalus after IVH by reducing inflammation, gliosis and apoptosis of the immature brain.44 45Administration of MSC is possible intranasally, with stem cells migrating or ‘homing’ to the injured regions within 2 hours46; this opens up great possibilities for treatment of preterm babies over the course of their stay in the NICU. A recent report highlights the presence of stem cells in breast milk and the intriguing possibility that nasal breast milk might exert neuroprotective effects in preterm infants.47 However, further clinical research is needed; on recent systematic review of clinical studies, there is no evidence of benefit of stem cell-based or exosome-based therapies for treatment of GMH-IVH, or any other brain injury in the preterm infant.48 Non-medical therapies Admission to the NICU has been associated with poor psychological functioning in mothers and fathers and negative parenting behaviours. The technical environment of the baby and NICU architecture may pose barriers to physical closeness.49 Animal data suggest that prolonged physical separation between parent and newborn alters brain development and results in higher cortisol levels in the infants50–52 and is associated with stress and anxiety in parents.53 Family-centred and developmental care practices are promising therapies with the potential to enhance the preterm baby experience and ameliorate the trajectory towards preterm birth MRI signature and phenotype. Developmental care is defined as the wide range of medical and nursing interventions that help to decrease the stress of preterm neonates in NICUs. These interventions are designed to allow optimal neurobehavioural development of the infant. A Figure 5 Prevalence of severe neurodevelopmental impairment in England (2006) compared with reported rates from recent international publications. Source: Mactier et al, BAPM 2019. NICHD, National Institute of Child Health and Human Development. Sciences Library. Protected by copyright. on May 17, 2021 at CU Anschutz Strauss Health http://fn.bmj.com/ Arch Dis Child Fetal Neonatal Ed: first published as 10.1136/archdischild-2020-319450 on 10 May 2021. Downloaded from F6 Soni R, et al. Arch Dis Child Fetal Neonatal Ed 2021;0:F1–F8. doi:10.1136/archdischild-2020-319450 Review large variety of interventions and environmental tools have been extensively studied—light and noise levels, scheduling of care according to the baby’s behaviour and state of sleep, limiting painful procedures, general