intensity of 40 dB delivered bilaterally using BAEP examination. Others: not assessed. Stoll et al.22 BSID II NDI: MDI o70, PDIo70, CP, bilateral blindness or bilateral hearing impairment. CP: a nonprogressive disorder characterized by abnormal tone in at least 1 extremity and abnormal control of movement and posture. Vision impairment: blindness in one or both eyes or need for corrective lenses. Hearing impairment: hearing aids in one or both ears. Hoekstra et al.23 BSID II (first 36 month). DDST, Early Language Millstone scale,34 and Zimmerman Preschool Articulation Test (between 3 and 6 year).35 NDI: mild-to-moderate impairment if examination revealed only minor abnormalities and developmental assessments were 6 to 12 months below their chronological age. Severe impairment if examination revealed severe abnormalities on physical and neurologic examinations and/or abnormalities on developmental assessment 1 year below their chronological age. CP, blindness and deafness: not defined. Hack et al.24 BSID II NDI: MDIo70, neurologic abnormality (CP, hypotonia hypertonia and/or shunt-dependent hydrocephalus), unilateral or bilateral blindness or deafness. CP: spastic diplegia, hemiplegia, hemidiplegia or quadriplegia (but did not assessed separately). Friedman et al.25 BSID II severe neurodevelopmental delay in infants with severe CP (not sitting by 2 years of age, nonambulatory), bilateral blindness, aided sensorineural hearing loss, severe cognitive delay with MDI, 70 (2s.d. below the mean) or shunted hydrocephalus. Tapia Collados et al.26 DDST and Amiel Tison test36 Moderate or severe: CP (hemiplegia, quadriplegia or diplegia), dystonia development coefficient o80, educational delay, persistent hyperactivity. Seizure or epilepsy, or hearing loss (o67 db). Msall et al.27 McCarthy scales of children abilities.37 Cattell Infant Intelligence Test or the Clinical Linguistic Auditory Milestone Scale (for children with a mental age o30 months)38 Major NDI: CP, mental retardation, blindness, deafness or multiple impairments. CP: early onset, none progressive motor and posture delays. Mental retardation: IQo67 Blindness: legal blindness or corrected vision worse than 20/200. Deafness: bilateral hearing impairment of 485 db. Case–control Lee et al.28 BSID (o24 months), Stanford–Binet Intelligence Scale39 and the Peabody Developmental Motor Scales for older children40 NDDs were diagnosed when one or more of the following were present: CP of all types or severity, (16,17) legal blindness (corrected visual acuity of the better eye, o20/200), hearing loss (neuro sensory hearing loss in the better ear 430 dB of better ear), and/or cognitive delay (MDI, 43 s.d. below the mean). Neurodevelopmental outcomes of VLBW infants with neonatal sepsis B Alshaikh et al 561 & 2013 Nature America, Inc. Journal of Perinatology (2013), 558 – 564 Strength and limitations To our knowledge, this is the first review study examining the pooled impact of sepsis in VLBW infants on long-term neurodevelopmental outcome. The use of different NDI definitions and follow-up methods resulted in significant heterogeneity during the assessment of the primary outcome; however, this disappeared when we examined the association between sepsis and CP. Despite that our analysis used non-randomized studies and unadjusted ORs, the sensitivity analyses and the biological plausibility support our present findings. In conclusion, our meta-analysis indicates that VLBW infants surviving sepsis in the neonatal period are at higher risk for neurodevelopmental disability including CP. This emphasizes the need for continued long-term follow-up of these infants. Avoiding neurodevelopment impairments associated with the sepsis in VLBW infants requires more research toward prevention of sepsis in this vulnerable population. Table 2. (Continued ) Study Scale Definitions Murphy et al.29 CP only CP: a permanent of impairment of voluntary movement or posture presumed to be damaged to the immature brain. Grether et al.30 CP only CP: chronic disability of CNS origin characterized by aberrant control of movement or posture, appearing early in life and not the result of progressive disease. Abbreviations: BAEP, brainstem auditory evoked potential; BSID, Bayley Scales of Infant Development 41; CP, cerebral palsy; DDST, Denver II developmental screening test; IQ, intelligence quotient; KSPD, Kyoto Scale of Psychological Development; MDI, mental developmental index; NDD, neurodevelopmental disability; NDI, neurodevelopmental impairment; PDI, psychomotor developmental index. Overall (I-squared = 36.9%, p = 0.064) Kono (2011) Cohort Collados (1997) Msall (1994) Study ID (year) Subtotal (I-squared = 0.0%, p = 0.550) Schlapbach (2011) Stoll (2004) Addison (2009) Hoekstra (2004) Subtotal (I-squared = Meta-analysis of neurodevelopmental outcome data from 17 studies using a random-effect model. CI, confidence interval; OR, odds ratio. Begg's funnel plot with pseudo 95% confidence limits log[or] s.e. of: log[or] 0 0.5 1 -2 0 2 4 Figure 3. Evidence of publication bias by funnel plot. Funnel plot asymmetry is exhibited by evidence of small studies with higher odds ratio and the paucity of small negative studies in the lower right of the funnel plot. Neurodevelopmental outcomes of VLBW infants with neonatal sepsis B Alshaikh et al