Premature birth is the most common cause for a stay in the neonatal intensive care unit (NICU) among neonates. Premature birth leads to prematurity, which is associated with complications such as respiratory distress syndrome (RDS), hyperbilirubinemia, gastroesophageal reflux (GERD), intraventricular hemorrhage , retinopathy of prematurity (ROP), and so on. These secondary complications are of great concern and need to be handled with care to prevent the further deterioration of the quality of life of the baby as he grows. So, the early physiotherapeutic interventional approach comes into light and plays an important role in neonatal care.This case study demonstrates an infant boy of seven months chronological age, who had a preterm birth history with a poor APGAR  score and NICU stay during the first three months of life. He approached the physiotherapy outpatient department with a complaint of delayed motor milestones like an absence of head holding, rolling, opening of hand, as well as delayed social-emotional development, Ryles tube (RT) in situ, with frequent episodes of GERD, neck rotated to the left side, high irritability, tactile defensiveness of both hands, and difficulty in regulating his sensory systems. Outcome measures used were gross motor function measure (GMFM), sensory profile, and rotating chair test. Early interventional physiotherapy was given including neurodevelopmental techniques (NDT), oromotor stimulation, sensory integration, passive stretching, and myofascial release for six days per week with each session of 45 minutes. The results demonstrated the achievement of motor milestones till sitting independently, reduced episodes of GERD, discontinued RT in situ, improved mobility of neck on both sides, reduced irritability, and started reaching, grasping along with bimanual tasks. Medical and technological advances in neonatal care during the mid to late 1900s led to the decreased mortality rate in neonates and increased the survival rate of very low birth weight infants resulting in increased incidences of cerebral palsy, respiratory disorders, blindness, cognitive delays, and hearing impairments globally . The phiPremature birth leads to prematurity, which is the commonest cause of neonatal intensive care unit (NICU) stay of infants. The prematurity is associated with medical complications like respiratory distress syndrome (RDS) , hyperbiThe term ‘early intervention’ refers to the multidisciplinary services provided to children from birth to six years of age to promote child’s health and well-being, enhance emerging competencies, minimize developmental delays, remediate existing disabilities, prevent functional deterioration, and promote adaptive parenting and family functioning . So, thiThis report is reporting a preterm infant boy (28th week of gestation) with the chronological age of seven months and a corrected age of 5.5 months. The mother of the infant had conceived by the in-vitro fertilization (IVF) twin pregnancy procedure. The mother presented to the inpatient department with cervical opening and intrauterine contraction at the time of the 28th week of pregnancy and hence underwent emergency cesarean section and gave birth to twin baby boys. The twin infant was developmentally appropriate for his chronological age. The weight of the infant at birth was 870 grams and his head circumference was 27 cm, he did not cry immediately after birth, APGAR  score was 5 at 1 min and 7 at 5 min. He was admitted to the NICU during the first three months of life during which he was on ventilatory support for the first 15 days and later shifted on continuous positive airway pressure (CPAP) and oxygen support for the remaining days of NICU stay. During his admission, he underwent surgery for an inguinal hernia at 2.5 months of age, following which he went through aspiration pneumonia, which was diagnosed as a case of gastroesophageal reflux disease (GERD) and managed by Ryles tube (RT) in-situ.At the physiotherapy OPD, the infant was presented with delayed motor milestones like the absence of head holding, rolling, opening of hand as well as delayed social-emotional development, RT in situ, with frequent episodes of GERD, neck rotated to the left side, positional torticollis, high irritability, difficulty in regulating sensory systems, and tactile defensiveness of both hands as shown in Figure The physiotherapeutic approach for the baby followed neurodevelopmental techniques, oromotor stimulation, sensory integration, and passive stretching with myofascial release. The details of each intervention following the FITT  principle are described in Table Preterm birth is a risk factor for developmental delay. This study identified the developmental risk and carried out the necessary physiotherapy treatment within the framework of early intervention studies. There’s an ample amount of literature available on the effectiveness of individual techniques of physiotherapy but this report has concentrated on the precision of the physiotherapy treatment protocol according to the patient’s need. Hence, the effective combination of neurodevelopmental techniques, oromotor stimulation, sensory integration, and passive stretching with the myofascial release was followed for the presenting patient. When pre and post-outcome measures were compared, it has been found that the infant has achieved a majority of motor milestones: started having semi-solid oral food in place of RT in-situ, started grasping for different textured toys, midline play with bimanual activity, improved visual tracking on the right side, decreased irritability, improved regulation, and started exploring the environment around him as shown in Figure Neuroplasticity, i.e., the neural tissue's ability to generate and reorganize the synaptic connections specifically to learning or following any injury, may be the possible reason for the positive outcome of early intervention therapy. An infant’s brain is not in a static phase, but it has the potential to change with different environmental cues, which may be the basis for neuro-rehabilitation. Brain development is proved to be dynamic at an early stage of life. According to literature, neonates in NICU are capable of responding to the internal and external changing environments .Early intervention is inclusive of the facilitation of neuromotor, sensory, oromotor, musculoskeletal, and social, language milestones. Neuro-developmental techniques facilitate normal posture and movement and hence help in the achievement of further growth and development of neonates .When all the results are evaluated, it can be considered that the combination of early intervention programs applied within the scope of the study served its purpose and has had a positive effect on all the individuals who are served with therapy.This case report has reported the effectiveness of the combination of the physiotherapeutic treatment techniques of neurodevelopmental techniques, oromotor stimulation, sensory integration, and passive stretching with myofascial release. The infant’s achievement of the majority of developmental milestones, being able to consume semi-solid food and getting rid of RT in-situ, identification and activity independence for grasping different textured toys, improvement in bimanual activities, improved visual response to the point of stimulation, improved behavior, and improved regulation and exploration of environment around him, made a significant demonstration on the effectiveness of the physiotherapeutic approach in preventing the delayed milestone complication in high-risk infants. The application of early intervention has been explored with an effort towards creating a new line of treatment for the increasing incidence of preterm birth complications.


Diffusion tensor imaging was performed on infants using a 3.0 Tesla Magnetic Resonance Imaging Scanner at 3 weeks. Maps of fractional anisotropy (FA) and mean diffusivity (MD) were constructed. A multiple linear regression was used to examine voxel-wise associations across the brain. Adjusting for postmenstrual age, sex, birth weight, and total energy intake revealed that maternal total and added sugar consumption were associated inversely and diffusely with infant MD values, not FA values. Inverse associations were distributed throughout all of the cortical mantle, including the posterior periphery  and frontal lobe . Our findings suggest that maternal total and added sugar intake during the second trimester are significantly associated with features of brain tissue organization in infants, the foundation for future functional outcomes.Animal studies have shown that exposure to excess sugar during the prenatal and postnatal periods may alter early brain structure in rat pups. However, evidence in humans is lacking. The aim of this study was to determine associations of maternal total and added sugar intake in pregnancy with early brain tissue organization in infants. Adolescent mothers ( Dietary sugar, including added sugar, has become pervasive in the current food environment ,2. This Our research team has particular interest in the influence of acute exposure to dietary sugar early in life on neurodevelopmental outcomes later in life. To date, our work has focused on the period of exclusive breast milk feeding. We have shown that maternal consumption of sugar-sweetened beverages made with high-fructose corn syrup increased fructose in breast milk during early lactation . MoreoveIt is plausible that exposure to any excess dietary sugar influences early brain tissue organization even before birth . MaternaThe aim of this study was to use Diffusion Tensor Imaging (DTI) to assess the associations of maternal dietary sugar consumption during the second trimester of pregnancy with early brain tissue organization of infants at three postnatal weeks. DTI is a Magnetic Resonance Imaging (MRI) modality that measures the diffusion of water in the brain, which is determined by characteristics of tissue microstructure.For this prospective cohort study, participants were 72 adolescent females recruited during pregnancy from the Departments of Obstetrics and Gynecology at Columbia University Medical Center (CUMC) and Weill Cornell Medical College. Mothers were included if they: (1) received routine prenatal care; (2) had no major health problems at time of recruitment; (3) were able to read English at a 5th grade level; and (4) were 14 to 19 years of age at time of delivery. Participants in this age group are classified as adolescents, who tend to consume more added sugar than any other age group ,26. Mothr = 0.89, p < 0.01) compared to the first trimester and third trimester. Infants underwent MRI scanning within the first few weeks of birth [Participant health-related information was abstracted from the medical record and included family health history, maternal health history, and infant characteristics at birth . Particiof birth .At the second trimester visit, maternal dietary intake was determined using the Automated Self-Administered 24-Hour (ASA-24) Dietary Assessment Tool from the National Cancer Institute. ASA-24 is a web-based questionnaire that collects food and beverage intake from the preceding 24 h with the use of detailed probes and scale images of portion sizes to assist in estimation of serving sizes. ASA-24 then determines the relative amounts of nutrients consumed from the preceding 24 h using three databases: (1) US Department of Agriculture (USDA) Food and Nutrient Database for Dietary Surveys; (2) USDA MyPyramid Equivalents Database (MPED); and (3) USDA Center for Nutrition Policy and Promotion’s MPED Addendum ,29. It iInfants completed MRI scanning procedures within 3 weeks of birth. Infants were fed, swaddled, and acclimated to the MRI scanning environment. Infants were allowed time to fall asleep on the MRI scanning bed before the start of each pulse sequence, without the use of sedation. Foam and wax ear plugs and ear shields were also applied to dampen scanning sounds . MRI-comInfant brain images were acquired using a 3.0 Tesla General Electric Signa MRI scanner with an 8-channel head coil. DTI was then used to assess the direction and rate of diffusing water, which is influenced by early brain tissue organization , and indexed by fractional anisotropy (FA), mean diffusivity (MD), axial diffusivity (AD), and radial diffusivity (RD). Briefly, FA is a measure of the preferential directional diffusion of water and reflects, among other things, the degree of myelination . MD is a2, flip = 90°, acquisition matrix = 132 × 128 (acceleration factor = 2) zero-padded to 256 × 256, for 60 oblique axial contiguous slices positioned parallel to the anterior–posterior commissure line, slice thickness = 2.0 mm [2 and 11 diffusion-weighted images at b = 600 s/mm2, with diffusion gradients applied in 11 directions sampling 3D space uniformly [DTI data were acquired in axial oblique slices parallel to the anterior–posterior commissure line using a single-shot echo planar DTI imaging sequence, with repetition time = 13,925 ms, echo time = 74 ms, field of view = 19 × 19 cmAD = We corrected magnetic field inhomogeneities, eddy-current distortions, and head motion using the FSL toolbox . We thenλ1>λ2≥λ3 , FA= for maternal total and added sugar values and plotted individual data points to find potential influential outliers. An influential outlier was defined as a data point with a iD value > 1 or with a iD value that stands out from the rest [p-values for regressions modeling maternal total and added sugar consumption were corrected for the number of statistical comparisons using the Benjamini–Yekutieli procedure for false discovery rate [p-values were color-coded and displayed on the template brain. All imaging analyses were conducted using software developed in-house.Descriptive statistics are presented as mean ± standard deviation (SD) for continuous variables and as frequency (percentage) for categorical variables. Normal distribution and homogeneity of variances were confirmed by Shapiro–Wilk W and Levene’s tests, respectively. We also calculated Cook’s Distances  and added sugar per day  during the second trimester of pregnancy were positively associated with reported intake during the third trimester.Characteristics of the mother–infant dyads are shown in B = −0.57, p < 0.001) and frontal lobe .Maternal consumption of total sugar did not correlate significantly with infant FA values in a consistent or convincing way anywhere in the brain. Maternal consumption of total sugar significantly correlated with infant MD values inversely and diffusely throughout the brain . These iB = −6.78, p < 0.001) and frontal lobe , as well as in the orbitofrontal cortex . In post hoc analyses, maternal consumption of total and added sugar were also found to be associated inversely and diffusely with infant AD and RD values in locations similar to those observed for MD values  in the hippocampus and frontal cortex ,23,24. IThis study has several limitations. The prospective observational design cannot be used to establish causality. Randomized controlled trials that manipulate maternal consumption of total and added sugar during pregnancy would be required to yield that level of causal inference. Though multiple covariates were included in our analyses, residual confounding caused by unmeasured factors could influence our findings. Information regarding maternal nutrition was based on self-reports, not direct observation or measurement. It is possible that participants underestimated (or overestimated) their consumption of total energy and dietary sugar per day ,59, thouIn conclusion, our findings revealed that maternal consumption of dietary sugar during the second trimester of pregnancy was associated inversely and diffusely with DTI-derived MD values in infants, a measure that reflects, in part, the anatomical foundation for future neurodevelopmental outcomes .


The study examined the development of Chinese as a second language learners’ formulaic knowledge through comparing the processing of Chinese idioms versus non-idiomatic formulaic sequences (FSs) by advanced-level learners (ALs), super-advanced learners (SLs), and native speakers (NSs). Using two phrase acceptability judgment tasks with and without think-aloud protocols, we collected data on participants’ processing accuracy, processing speed, and processing strategies of reading the two types of FSs. Four processing patterns emerged from the analyses of the datasets. First, learners’ processing accuracy and speed increased along with their proficiency. Second, learners’ idiom processing ability was generally lower than that of non-idiom processing ability, but they demonstrated an improving trend as their proficiency level increased. Third, learners’ use of processing strategies did not change much as proficiency rose and demonstrated a categorical difference from NSs. Fourth, all three groups exhibited poorer productive idiom knowledge than productive non-idiom knowledge. The overall findings denote that second language learners’ formulaic knowledge can evolve beyond the lexical plateau as learners move from the advanced to a higher proficiency level, but the productive idiom knowledge can be a long-term problem. The findings provide implications for measuring and teaching Chinese formulaic knowledge at the higher-than-advanced stage. In second language acquisition (SLA), the two primary goals are to identify the nature of learners’ linguistic knowledge and to provide accounts for how this knowledge transforms over time . SpecifiIn the last two decades, mounting evidence has suggested that overall second language (L2) proficiency can be improved by acquiring formulaic sequences (FSs), which are multiword expressions that frequently recur as a whole in language use . This clDespite the general acknowledgment of the importance of learning formulaic knowledge, little is known about how formulaic knowledge develops as learners’ proficiency increases. Some corpus-based studies e.g.,  focused In the FS literature, there is a severe lack of studies gauging the development of L2 formulaic knowledge. This scarcity of research may have to do with certain characteristics of FSs. We review these characteristics and the related empirical findings in the following sections.Formulaic sequences lack homogeneity. Different types of FSs vary greatly in their linguistic dimensions, such as idiomaticity, form fixedness, function, and linguistic register . For exaIn NSs’ FS processing, although researchers generally agree that FSs have a processing advantage over non-formulaic novel phrases, In L2 learners’ FS processing, studies focusing on different kinds of FSs have often reported different processing patterns. For example, by examining idiomatic FSs, Due to conflicting findings, researchers have recently begun to call attention to the necessity of empirically comparing different types of FSs in SLA-oriented studies to discern the sources of learners’ processing difficulties, and to better integrate findings about FS processing into FS acquisition . The mosChinese FSs share the universal characteristics that have been observed in FSs of other languages. They also lack homogeneity, and studies on the processing of different types of Chinese FSs by CSL learners have also reported conflicting results. For example, set-language  and 惯用语 Guan-yong-yu habitual-use-language , may be the thorniest type for L2 learners. Chinese idioms are often “composed in Classical Chinese and thus typically have a different grammatical structure from that of Modern Chinese” Do ALs, SLs, and NSs demonstrate different patterns in FS processing accuracy?(2)Do ALs, SLs, and NSs demonstrate different patterns in FS processing speed?(3)Do ALs, SLs, and NSs demonstrate different patterns in their FS processing strategies?HSK:HangyuShuipingKaoshi) volunteered to participate. Before the main test, the participants took an online character quiz designed and distributed by the APP Wenjuanxing questionnaire. On the quiz, the participants were asked to associate each character with its correct meaning on a multiple-choice task. The characters included (but were not limited to) all the characters that would appear in the testing materials. All characters were within the required vocabulary range of the HSK 6 guidelines, so presumably the participants would already know all the characters. Knowing all target characters is important because it can confirm that any observed processing problems are NOT due to the presence of unknown words in the FSs. Finally, we included 26 learners (mean age = 26) who achieved a score of 100% on the quiz on the main test. Another 13 NS participants were undergraduate and graduate students recruited from two universities in Beijing (mean age = 27). None of them were Chinese language or literature majors.The participants included 13 ALs, 13 SLs, and 13 NSs. Although a larger sample size is always desirable for lexical research to iron out individual variances, The 26 L2 participants came from four Chinese universities and were enrolled in three types of programs: (1) language degree programs designed for foreign students to learn Chinese for general and specific purposes; (2) discipline programs  that mostly enroll Chinese undergraduate students and some very advanced foreign students who are able to use Chinese in academic settings; and (3) preparatory programs designed to prepare advanced foreigners to enter into discipline-focused programs. The background information about the L2 participants is presented in t-tests confirmed that the two groups’ HSK scores were significantly different . Other than HSK scores, we also considered years of learning the language and current enrollment programs. n of learners in a discipline-focused program = 8, n of preparatory program learners = 4, n of language program learners = 1) would be considered more advanced than the bottom 13 scorers, who were mostly learners in language programs . Moreover, We further divided the 26 learners into two proficiency groups. Because the HSK test does not have official guidelines to differentiate advanced and higher-than-advanced levels of proficiency, we used learners’ HSK scores as the primary criterion to distinguish their proficiency levels. We grouped the 13 highest scorers together (mean score = 247.77) and the 13 lowest scorers together (mean score = 206.54). Independent not be read in a verbatim fashion.The two types of FSs used in this study were Chinese idioms and non-idiomatic FSs. Because we differentiated FSs by the domain of idiomaticity, we treated subtypes of non-idiomatic FSs  as one category. For both idioms and non-idioms, we also manipulated the sequence length by using three-character (3-C) sequences and four-character (4-C) sequences with matched whole-form frequency. The rationale is that because 4-C items are one character longer than 3-C items, if 3-C items are processed significantly faster than 4-C items of the same FS type, then it is very likely that the FSs will be visually recognized in a word-by-word fashion. If the length does not play a significant role in processing speed, then it is more likely that the FSs will The Contemporary Chinese Dictionary (6th edition). We tried to be as exhaustive as possible. This procedure yielded a total of 2,098 4-C idioms and 3,783 3-C idioms. The 4-C idioms are all 成语 Cheng-yu; the 3-C idioms include both 惯用语 Guan-yong-yu and semantically non-transparent, verb-complement structures . Second, we ran the two types of idioms in the Google 1-gram database. Given the raw token frequency, we further extracted the top-ranked 300 items in each type. Then, by consulting with two experienced Chinese language teachers, we selected 38 3-C and 38 4-C idioms that are more likely to be familiar to advanced learners and have comparable whole-form frequencies for the idiom pool. Finally, using a 5-point scale, 33 Chinese language teachers rated these idioms based on the likelihood that an advanced Chinese learner would know them. Finally, we included 24 3-C idioms and 24 4-C idioms that received an average score of 4 or higher  they are grammatical phrases commonly used in modern Chinese; (2) they have equal numbers of characters and similar constructions to the matched idioms; (3) they share at least one identical content character with the matched idioms; and (4) they have comparable total stroke numbers and whole-form frequency to the matched idioms. Independent samples t-tests (a = 0.0125) showed no significant differences in the 3-C idiom and 3-C non-idiom frequencies  or stroke numbers . The 4-C idiom and 4-C non-idiom frequencies were also not significantly different , nor were their stroke numbers . The Independent samples t-tests also confirmed that the 24 3-C idioms and 24 4-C idioms were matched in whole-form frequency , as were the 24 3-C non-idioms and 24 4-C non-idioms .Because we aimed to compare the processing of idioms and non-idiomatic FSs, we matched each idiom with non-idiomatic FSs through the following steps. We first changed one constituent word of the target idiom and waited to see if the new expression would be grammatical, and if the whole-form frequency and total stroke number were matched with the target idiom . If changing one character failed, we continued to change two characters . If changing two characters also failed, we used the fuzzy search function provided in the BCC corpus and looked for a potentially non-idiomatic expression that shared at least one content character with the target idiom . After several rounds of matching, we found that some of the chosen non-idioms were absent from the existing Chinese frequency corpora. To solve this problem, we adopted n = 24) and (2) matched 3-C non-idioms (n = 24) and (3) 4-C idioms (n = 24) and (4) matched 4-C non-idioms (n = 24). Another 96 ungrammatical phrases were made up as fillers. We divided the test stimuli into two counterbalanced blocks so that the participants would not read an idiom and its matched non-idiom in the same block.In sum, the test stimuli in  consisteWe programmed the speedy acceptability judgment task using Paradigm software to collect judgment accuracy data and response time data. Acceptability judgment task paradigms have been widely used in the SLA field to measure learners’ L2 competence e.g., . BecauseWe conducted the think-aloud phrase acceptability judgment task 1 week after each participant finished the speedy acceptability judgment task. This task allowed us to examine participants’ thought processes when they judged the phrases. The purpose was to infer what processing strategies were used by different groups of participants and for different types of FSs. As a versatile data collection tool, the think-aloud method has been broadly employed in L2 studies to gather data about learners’ thought processes to measure processing strategies , depth oIn previous SLA research, think-aloud protocols can be classified into two types—metalinguistic and non-metalinguistic—each tapping into different kinds of knowledge and having different techniques. The metalinguistic think-aloud protocols—which are carried out by asking participants to provide justifications for their performance—tap into metalinguistic knowledge. The non-metalinguistic think-aloud protocols—which are conducted by simply asking the participants to verbalize whatever is on their minds while performing a task—tap into general cognitive processes see . The disI just feel it’s correct” or “我听过这个 I’ve heard of this.” On the test, we used the same set of test stimuli and a different set of filler stimuli. The test stimuli were presented one by one on a computer screen controlled by a research assistant. Because L2 learners were also asked to verbalize in Chinese, they were informed that they need not worry about language errors, because the purpose of the task was to understand their thought process, rather than testing verbal proficiency ”“请判断这个短语在汉语里能不能说，请说出您是怎么知道的。就把您思考时在脑子里对自己说的话大声说出来，就好像您独自坐在一个房间里跟自己说话一样。不用在意说的句子语法对不对，完整不完整，因为我们只想了解您在做判断时的想法。 ”. When developing the coding book, we consulted one grammaticality judgment study and one idiom processing study. In We coded the participants’ think-aloud reports for processing strategies. In this study, “processing strategy” refers to what type of information a participant relied on to make a judgment. A participant could use his/her intuition and say, “n = 750) independently. The intercoder reliability reached 95.3% (Cohen’s Kappa = 0.829). The agreement was considered high enough for one assistant to code the remaining data alone.Two trained research assistants coded approximately 20% of the think-aloud data . To analyze processing speed, we transformed the raw response time data by log10 to reduce skewness . We excluded incorrect responses to target items, which led us to remove 1.9% of the NS data, 5.7% of the SL data, and 16.3% of the AL data. We further trimmed the extreme data by setting the cutoffs at three standard deviations from each participant’s mean response time. This procedure removed an additional 1.1% of the NS data, 0.7% of the SL data, and 0.6% of the AL data. To analyze processing strategies, we included all think-aloud data .To analyze processing accuracy, we included all judgment data. Because the selected testing materials were highly familiar to NS participants and most non-native participants, the dichotomous judgment data (processing accuracy) were supposed to be positively skewed  and the interaction of group × type  and type × length . The effect of type was marginally significant , while the effect of length  and the group × length interaction  were both non-significant.The dichotomous judgment data were then analyzed via a generalized linear mixed-effects model in R using the lmerTest package. When fitting the models, we entered the variables of group, length, and type as fixed effects. We added the participants and items as random effects, including the random intercepts of participants and items and the random slopes for all fixed effects. When dealing with the multicollinearity issue, we excluded the three-way interaction of group × type × length from the model because the two-way interactions and the planned p < 0.000), NSs and SLs (p < 0.000), and ALs and SLs (p < 0.001). NSs’ judgments were more accurate than those of the two groups of learners, and SLs’ judgments were more accurate than those of the ALs. The analyses for the effect of type × group indicate that idioms were judged significantly more accurately than non-idioms by NSs (p = 0.012), while idioms were judged significantly less accurately than non-idioms by ALs (p = 0.024). SLs’ judgments of idioms and non-idioms were only marginally different (p = 0.061). This finding suggests that NSs’ recognition of idioms was more successful than their recognition of non-idioms, implying that idioms were more deeply entrenched in the NSs’ lexicons and therefore unlikely to be recognized incorrectly. For CSL learners with a relatively low proficiency level, the results hint that they were better at judging semantically transparent or syntactically regular sequences than the irregular formulae. For learners with a higher proficiency level, their judgment ability of the irregular formulae developed and approached their judgment ability of the regular formulae. The analyses for the effect of length × group demonstrated no significant results for NSs (p = 0.623), SLs (p = 0.297), or ALs (p = 0.747), thereby suggesting that longer FSs were recognized as successfully as shorter FSs by all three groups of participants.We then conducted the planned pairwise comparisons. The analyses for the effect of group show that the judgment accuracy was significantly different between NSs and ALs , length , the interaction for group × type , group × length , and group × type × length . The effect of type  and the interaction for type × length  were non-significant.The log10-transformed response time data were then sent into a linear mixed-effects model with group, type of FSs, and length of FSs included as fixed effects. We added the participants and items as random effects, beginning with a maximal random effects structure encompassing random intercepts for participants and items, and random slopes for all fixed effects. The outcomes showed a clear effect for group (p < 0.000), NSs and SLs (p = 0.017), and ALs and SLs (p < 0.000). Further, NSs outperformed the two learner groups, and the SLs outperformed the ALs. The analyses for the effect of group × type revealed that idioms and non-idioms were processed at a significantly different speed by NSs (p = 0.002), with idioms being processed faster than non-idioms, and by ALs (p = 0.019), with idioms being processed more slowly than non-idioms, but the difference was non-significant for SLs (p = 0.268). This pattern indicates that learners with lower proficiency might spend more cognitive effort processing semantically or syntactically irregular formulae than regular ones. As proficiency approached the near-native level, the cognitive efforts spent on irregular forms decreased, thereby generating comparable processing speed for idioms and non-idioms. For NSs, the processing pattern was reversed, as idioms were processed more effortlessly than non-idioms, suggesting that idioms might be pre-listed in NSs’ mental lexicons. The analyses for the effect of group × length showed that the processing speed of 3-C versus 4-C FSs was significantly different for the NS group (p = 0.002), with 4-C FSs being processed faster than 3-C FSs. A significant length effect was also found for the SL group (p = 0.002) and the AL group (p = 0.002). However, both with 3-C FSs were processed more quickly than 4-C FSs. The findings of the length effect for SLs and ALs were explainable, as the longer sequences required a longer time to read. Notwithstanding, the finding for NSs was counterintuitive. We computed the planned pairwise comparison for length × type for the NS group. The length effect existed only in the processing of idioms, with 4-C idioms responding significantly faster than 3-C idioms (p = 0.011), but the difference between 3-C non-idioms and 4-C non-idioms was non-significant (p = 1.00).To explore the differences between the levels of each variable, we performed planned pairwise comparisons. The analyses for the effect of group showed that processing speed was significantly different between NSs and ALs  by group. The results are presented in RQ3: It is just an idiom.” Learners either relied on their feelings or confessed that “I have learned this but forgotten its meaning.” When using intuition with non-idioms, all three groups of participants provided a cliché type of answer, such as “A just means A” or “It is just what I often say” without further elaboration. That NSs could quickly recognize idioms suggests that idioms are a very salient FS type in NSs’ mental lexicons. In contrast, learners’ feelings and confessions imply that idioms might not have been fully acquired. The cliché reports hint that both NSs and learners’ non-idiomatic FS knowledge had become proceduralized.Intuition was used more frequently by NSs; 38.8% of idioms and 35.9% of non-idioms were processed with intuition by NSs. SLs used intuition for 22.3% of idioms and 28% of non-idioms. ALs used intuition for 25% of idioms and 19.4% of non-idioms. When using intuition with idioms, NSs often immediately identified the idioms, saying, “The example strategy was more frequently used for non-idioms than idioms by all three groups. NSs provided examples for 53.4% of non-idioms, SLs for 45.7% of non-idioms, and ALs for 40.5% of non-idioms. For idioms, an example strategy was used 31.4% of the time by NSs, 19.9% of the time by SLs, and 17.9% of the time by ALs. In using the example strategy, the participants either described a typical situation in which an FS often occurs or directly used the target FS to make a sentence. Being able to use an FS in a real situation is evidence of the possession of proceduralized knowledge . The preTarget idiom: 脱口而出 cast-mouth-and-out “blurt out”I ‘tuo-kou-er-chu’ and spit sputum.)”An NS’s report: “我脱口而出吐了一口痰. .”An AL’s report: “嗯，这个，看起来是对的。比如说，嗯，我、我、我好久都没有跟你说什么，终于 脱口而出. ; the other is to propose an interpretation for an unfamiliar FS (which is the case for some learners’ interpretations).In the latter case, learners are often based on the constituent word’s meaning and their logical thinking to make sense of the unknown FS, sometimes resulting in an erroneous interpretation. An example is shown below.Target idiom: 千方百计 thousand-method-hundred-plan “to make every possible effort to”Correct. Should…I think that the meaning should be ‘having many plans?’)”An AL’s report: “是对的, 应该.…… 我觉得解释应该是有很多计划. (wish you a happy voyage” vs. 一帆风顺 one-sail-wind-smooth “wish everything go smoothly”). Learners also associated a similar expression in their L1. The association strategy suggests that learners store their FS knowledge in a network fashion . When employing this strategy, both NSs and the two groups of learners would associate synonyms or antonyms, but only learners confused the target FS with another Chinese FS with a similar form, but not exactly the same meaning  was legitimate to be used in isolation. Metalinguistic analysis is often considered evidence of accessing explicit knowledge  and non-idioms (13.6%). NSs employed metalinguistic strategies less than 1% of the time, and SLs used zero metalinguistic strategies. By scrutinizing the think-aloud reports, we found that NSs’ metalinguistic cases often involved questioning whether a lexical bundle ”An AL’s report: “应该是对的, 因为谈和说有关的, 天和地有关的, 但是怎么用……不知道. ”This study examined the processing of Chinese idiomatic and non-idiomatic FSs among three groups of participants with different levels of proficiency. Due to the relatively small sample size, the findings should be considered to be tentative answers to our three research questions.This question aimed to compare AL, SL, and NS processing patterns through dichotomous judgment data. The analysis of the dichotomous judgments returned significantly different processing patterns among the three groups. NSs judged idioms more successfully than they judged non-idioms. ALs judged non-idioms more successfully than they judged idioms. SLs judged non-idioms slightly more accurately than they judged idioms, but the difference was marginal. The length effect was absent in all three groups. These patterns suggest that idioms are more deeply entrenched in NSs’ long-term memory than non-idioms and are thus unlikely to be recognized as wrong. For ALs, both types of FSs might not have been fully acquired, but since non-idioms are semantically and syntactically transparent forms, their correctness is easier to judge than idioms. SLs were almost equally successful with idioms and non-idioms, indicating that in the super-advanced stage, learners’ idiomatic knowledge improved compared to that in the advanced stage.This question aimed to compare AL, SL, and NS processing patterns through reaction time data. For NSs, idioms were processed significantly faster than non-idioms, regardless of the length of the FSs. In the AL group, we observed a reversed pattern; non-idioms were processed significantly faster than idioms were. Longer FSs took a significantly longer time to process than shorter ones did. For SLs, idioms were processed as fast as non-idioms, but longer FSs still required significantly longer processing times than shorter FSs. The presence of a length effect in the AL and SL groups suggests that learners were likely to read both idioms and non-idioms in a word-by-word fashion. For ALs whose idiom knowledge was quite limited, judging the correctness of an idiom may have largely relied on the online computation of the constituent words. Because idioms are semantically non-transparent forms, computing and making sense of an idiom would require more time than computing and making sense of a transparent non-idiom. However, SLs who possess better idiom knowledge still need to read an idiom word-by-word in the initial stages, but after they have reached the idiom key—the constituent word that determines when an idiom form can be recognized as an idiom —they areThis question aimed to compare AL, SL, and NS processing patterns through think-aloud data. We coded think-aloud statements for five levels of processing strategies. The frequency analysis showed that the two learner groups used different processing strategies from the NS group. NSs preferred to use the example strategy, while learners preferred to use the interpretation strategy. This pattern suggests that the nature of NSs and learners’ formulaic knowledge may be fundamentally different. Being able to provide examples indicates that NSs’ formulaic knowledge has become proceduralized. Providing interpretations implies that learners’ formulaic knowledge might still be descriptive . In addiIn sum, the following processing patterns emerged from the analyses of processing accuracy, speed, and strategy. First, the participants’ processing accuracy and global processing speed increased along with their proficiency. Second, CSL learners’ idiom processing ability was generally lower than that of non-idiom processing ability, but they demonstrated an improving trend as their proficiency level increased. Third, CSL learners’ use of processing strategies did not change much as proficiency rose and demonstrated a categorical difference from NSs. Fourth, all three groups exhibited poorer productive idiom knowledge than productive non-idiom knowledge.In the analyses of processing accuracy and processing speed, we found that SLs’ processing patterns were significantly different from those of ALs. From the advanced to the super-advanced levels, the learners changed from being more successful at non-idiom processing to being equally successful at non-idiom and idiom processing, marking a transition toward NS performance (being more successful at idiom processing). This finding suggests that formulaic knowledge can grow substantially as learners move from an advanced to a higher proficiency level.In the SLA literature, higher-than-advanced learners have long been overlooked. A major reason for this is that the number of achievers is very small, especially for learners of a non-English language such as Chinese. Another reason may have to do with the general assumption of the lexical plateau  with idioms than with non-idioms. Poor idiom competence was also reported by As for why using idioms is problematic, there are multiple reasons for learning difficulties. The primary one is the semantic opaqueness of idioms. Because of semantic and syntactic idiosyncrasies, learning idioms largely depends on rote memorization , which cAnother finding we would like to consider is the processing strategy used by the three groups of participants. Although the processing accuracy and speed data demonstrate a trend whereby L2 learners’ FS knowledge increased as they moved from the advanced to the super-advanced levels, the learners’ processing strategy pattern basically remained unchanged. While NSs used the example strategy the most, both ALs and SLs employed the interpretation strategy the most. The use of examples indicates that NSs can interact with FSs in a communicative manner, which represents a high degree of knowledge mastery. In contrast, the interpretation strategy involves describing or inferring FSs’ meaning; both cases suggest that CSL learners’ formulaic knowledge is descriptive and static . The queAlthough the experimental design enabled a controlled comparison of two types of formulae among three groups of Chinese speakers with different proficiency levels, a fact which had not been fully examined in the FS literature, we must acknowledge some limitations. First, the sample size of our study was relatively small; thus, the answers are more tentative than conclusive. Although higher-than-advanced learners are very scarce, endeavors could be made to conduct a larger-scale study.Another issue is the homogeneity of the FSs. In this study, we could subdivide both idioms and non-idioms. For example, non-idiomatic FSs included lexical collocations and lexical bundles. According to Regarding the methodology of think-aloud protocols, there may be the issue of reactivity; i.e., the possibility that thinking aloud may alter participants’ cognitive processes . AlthougAnother methodological issue concerns the use of NSs as the baseline group. According to our findings, NSs do not necessarily possess full idiom knowledge, especially productive idiom knowledge. Thus, future studies involving idiom production should carry out a preliminary test to confirm that the chosen NSs are eligible to serve as indexing norms.The original contributions presented in the study are included in the article/The studies involving human participants were reviewed and approved by University of Illinois at Urbana-Champaign. The patients/participants provided their written informed consent to participate in this study.HZ designed the study, performed the experiments, analyzed the data, and wrote and edited the manuscript. BH analyzed the data, reviewed, and revised and edited the manuscript. JX supervised the research, analyzed the data, and reviewed the manuscript. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


To describe the pregnancy and neonatal outcomes using fresh and vitrified/warmed blastocysts obtained from ovarian stimulation with follitropin delta in controlled trials versus follitropin alfa.This investigation evaluated the outcome from 2719 fresh and frozen cycles performed in 1326 IVF/ICSI patients who could start up to three ovarian stimulations in the ESTHER-1 (NCT01956110) and ESTHER-2 (NCT01956123) trials, covering 1012 fresh cycles and 341 frozen cycles with follitropin delta and 1015 fresh cycles and 351 frozen cycles with follitropin alfa. Of the 1326 first cycle patients, 513 continued to cycle 2 and 188 to cycle 3, and 441 patients started frozen cycles after the fresh cycles. Pregnancy follow-up was continued until 4 weeks after birth.The overall cumulative take-home baby rate after up to three stimulation cycles was 60.3% with follitropin delta and 60.7% with follitropin alfa , of which the relative contribution was 72.8% from fresh cycles and 27.2% from frozen cycles in each treatment group. Across the fresh cycles, the ongoing implantation rate was 32.1% for follitropin delta and 32.1% for follitropin alfa, while it was 27.6% and 27.8%, respectively, for the frozen cycles. Major congenital anomalies among the live-born neonates up until 4 weeks were reported at an incidence of 1.6% with follitropin delta and 1.8% with follitropin alfa .Based on comparative trials, the pregnancy and neonatal outcomes from fresh and frozen cycles provide reassuring data on the efficacy and safety of follitropin delta.ClinicalTrials.gov Identifier: NCT01956110 registered on 8 October 2013; NCT01956123 registered on 8 October 2013.The online version contains supplementary material available at 10.1007/s10815-021-02271-5. Ovarian stimulation with recombinant follicle-stimulating hormone (FSH) preparations produced using Chinese Hamster Ovary (CHO) cells  results in acceptable success rates in terms of pregnancy  and studToday, recombinant FSH preparations are available from new types of mammalian cell lines. Follitropin delta is the most recently developed recombinant FSH preparation, and it is the first commercially available recombinant FSH expressed from a human cell line PER.C6®). While follitropin alfa, follitropin beta, and follitropin delta have the same amino acid FSH sequence, follitropin delta resembles native human FSH with α2,6-linked sialic acid and bisecting N-acetylglucosamine, which are not present in follitropin alfa and follitropin beta –6. These®. While Comprehensive clinical trials have been performed in in vitro fertilization (IVF)/intracytoplasmic sperm injection (ICSI) patients undergoing ovarian stimulation to document the efficacy and safety of follitropin delta versus CHO-derived recombinant FSH preparations –13. The Evidence-based Stimulation Trial with Human rFSH in Europe and Rest of World 1  was a randomized, controlled, assessor-blind trial comparing individualized follitropin delta dosing versus conventional follitropin alfa dosing, following a gonadotropin-releasing hormone (GnRH) antagonist protocol (fresh cycle 1) [This integrated analysis was conducted with data from two controlled clinical trials in the development program for follitropin delta that were performed between October 2013 and January 2017 at 37 investigational sites in Europe and North and South America. The cycle 1) , or had In fresh cycle 1, the follitropin delta  dosing regimen was individualized based on patient’s serum anti-Müllerian hormone  and body weight, and no dose adjustments were made during stimulation. The follitropin alfa  dose was 150 IU/day for the first 5 days and could thereafter be adjusted. In subsequent cycles, the starting doses were maintained or adjusted according to the ovarian response in the previous cycle. The maximum allowed daily dose of follitropin delta was gradually increased from 12 μg in fresh cycle 1 to 18 μg in fresh cycle 2 and to 24 μg in fresh cycle 3. The maximum allowed daily starting dose of follitropin alfa was 150 IU, 225 IU, and 300 IU in fresh cycles 1, 2, and 3, respectively, with a maximum allowed daily dose of 450 IU in all three cycles. Patients with surplus of day 5 blastocysts as well as patients who underwent triggering of final follicular maturation with GnRH agonist could undergo frozen cycles. Blastocysts were cryopreserved in individual straws using the vitrification method. The transfer policy in the fresh cycles was determined by age and blastocyst quality, with guidance to transfer either one or two blastocysts. In the frozen cycles, one or two blastocysts could be transferred from one or several of the fresh cycles at the discretion of the investigator and patient, and in accordance with local practice. Both natural cycle and programmed regimens were allowed. Pregnancy follow-up was done until 4 weeks after birth for all pregnancies resulting from fresh cycles or frozen cycles started within 1 year after start of stimulation of the last fresh cycle in either of the trials. Additional details on trial design, population and baseline characteristics, procedures, and results, including CONSORT flow diagrams, are available in previous publications , 13.The main outcomes were the overall cumulative take-home baby rate for women exposed to follitropin delta and follitropin alfa in the ESTHER trials as well as the neonatal health data up until 4 weeks after birth.Live birth was defined as the birth of at least one live baby after ≥24 weeks of gestational age. The cumulative take-home baby rate  from fresh and frozen cycles for each stimulation cycle in which the women participated was calculated. A started frozen cycle was defined as a cycle with warming of at least one blastocyst with the intention of transfer. The ongoing implantation rate (defined as the number of intrauterine viable fetuses 10-11 weeks after transfer divided by number of blastocysts transferred) was determined across all fresh cycles as well as all frozen cycles.Neonatal outcomes included neonatal characteristics such as gestational age, gender, birth weight, and length at birth as well as safety variables like congenital anomalies, stillbirth (defined as death of a fetus after ≥24 weeks of gestation), neonatal death (defined as death of a live-born neonate within 4 weeks after birth), admission to neonatal intensive care unit (NICU) or neonatal care unit (NCU) within 24 h after birth, and also hospitalization occurring between 24 h and 4 weeks after birth.Singleton and multiple status were based on the number of intrauterine viable fetuses at the ongoing pregnancy visit performed 10-11 weeks after transfer. Gestational age was calculated as the days between blastocyst transfer and birth plus 19 days. A birth weight <2500 g was defined as low birth weight, and <1500 g was defined as very low birth weight .Congenital anomalies detected in fetuses, neonates within 24 h after birth (referred to as “at birth”), and neonates between 24 h and 4 weeks after birth (referred to as “at 4 weeks after birth”) were reported after assessment and diagnosis by the neonate’s physician and coded using the Medical Dictionary for Regulatory Activities (MedDRA) versions 18.1 and 19.1. As per regulatory guidelines, major congenital anomalies were defined as a life-threatening structural anomaly or one likely to cause significant impairment of health or functional capacity and which needs medical or surgical treatment, and minor congenital anomalies were defined as a relatively frequent structural anomaly not likely to cause any medical or cosmetic problems . The catDescriptive statistics are presented without accounting for multiple records for a patient. Cumulative take-home baby rates were compared between treatments by constructing a two-sided 95% confidence interval (CI) for the estimated mean difference in rates  using the Mantel-Haenszel method to combine risk differences across age strata . Ongoing implantation rates per started cycle with blastocyst transfer were compared between treatments using a mixed effect logistic regression model with treatment, age stratum, and single/double transfer as fixed factors and patient as random effect, assuming normally distributed log-odds. The estimated mean difference and 95% CI were derived using the delta method. Similarly, the take-home baby rates per started cycle were compared between treatments using a mixed effect logistic regression model with treatment and age stratum as fixed factors and patient as random effect. The 95% CIs were calculated to estimate the mean difference in incidence of major and minor congenital anomalies using the method of Wald. All statistical analyses were performed using the SAS software .In this integrated analysis of data from comparative controlled trials with fresh and frozen cycles, 1326 women underwent a total of 2719 cycles: 1353 cycles in the follitropin delta group and 1366 cycles in the follitropin alfa group   of the clinical pregnancies detected at 5–6 weeks after transfer in the follitropin delta group and 1.0% (5/486) of the clinical pregnancies in the follitropin alfa group after fresh and frozen cycles , including 6 cases of trisomy 13, 18, and 21 . Finally, minor congenital anomalies, defined as relatively frequent structural anomalies not likely to cause any medical or cosmetic problems, were more common than major congenital anomalies. The incidence of live-born neonates with minor congenital anomalies after fresh and frozen cycles was 4.8% (21/433) in the follitropin delta group and 3.0% (13/440) in the follitropin alfa group .The present comprehensive data set from comparative controlled trials provided reassurance on all outcomes, including ongoing implantation rate, take-home baby rate, and neonatal health, in fresh and frozen cycles following ovarian stimulation with follitropin delta, a recombinant FSH preparation expressed from a human cell line.Following follitropin delta treatment, the ongoing implantation rate in fresh cycles, the availability of cryopreserved blastocysts, the survival rate for warmed blastocysts proceeding to transfer, and the ongoing implantation rate in frozen cycles were comparable to follitropin alfa. Moreover, the risk of stillbirth was low, which is in line with previous reports . Across In terms of neonatal outcomes, the vast majority of births in these trials resulted in the delivery of healthy neonates. The neonates born after ovarian stimulation with follitropin delta and follitropin alfa demonstrated comparable neonatal outcomes, with no difference regarding gestational age and birth weight. The incidence of congenital anomalies after the use of follitropin delta was within the range of what previous studies on congenital anomalies in neonates born after ovarian stimulation have found , 19–25, There are several studies in the literature reporting differences in neonatal outcomes between fresh and frozen cycles , 27–33, The present analysis focused on the take-home baby rate using the data available at 4 weeks after birth. This endpoint is clinically relevant, as it accounts for the losses occurring in the immediate period after birth that are not reflected in the standard reporting of live birth rate. Furthermore, the 4-week follow-up time frame allowed for reporting of those congenital anomalies that are difficult to detect at birth, and comprised 6 of the 21 major congenital anomalies in the present analysis, and therefore also ensured a more complete analysis of neonatal health. The time period of the analyzed frozen cycles covered 1 year after start of the last ovarian stimulation cycle, which seems adequate considering that the cumulative take-home baby rate plateaued after one or two frozen cycles. Nevertheless, this integrated analysis of data was influenced by the individual trial designs, including that a limited proportion of patients proceeded to a new ovarian stimulation cycle before using all cryopreserved blastocysts.This report compiles the most comprehensive data set of pregnancy and neonatal outcomes in fresh and frozen cycles following ovarian stimulation with a recombinant FSH preparation expressed from a human cell line. The reported take-home baby rate and observed neonatal outcomes with follitropin delta across fresh and frozen cycles in controlled trials with follitropin alfa as a reference add reassuring information on the clinical performance of follitropin delta in terms of efficacy and safety.ESM 1(DOC 215 kb)


Birth weight, birth length, and gestational age are major indicators of newborn health. Several prenatal exposure factors influence the fetal environment. The aim of the study was to investigate the effect of prenatal exposure factors, including socio-demographic, behavioural, dietary, physical activity, clinical and environmental on birth outcomes through the mediation of Favourable Fetal Growth Conditions (FFGC).Data was obtained from six hundred and fifty-six Mother and Child in the Environment birth cohort study in Durban, South Africa from 2013 to 2017. We adopted structural equation models which evaluate the direct and indirect effects by allowing multiple simultaneous equations to incorporate confounding and mediation.newborn weight, length, and gestational age was seen. Gestational weight gain and maternal body mass index in the first trimester exerted a mediation effect between maternal behavioural risk factors and FFGC. Similarly, the level of physical activity during pregnancy was associated with decreased gestational weight gain. The effects of maternal characteristics on newborn weight, length, and gestational age were largely indirect, operating through FFGC as a latent variable.A significant direct and indirect effect of FFGC on Gestational weight gain and maternal pre-gestational BMI were observed to mediate the association between prenatal behavioural risk factors and favourable fetal growth conditions.Retrospectively registered from 01 March 2013. Fetal development is a global public health concern because growth in utero is a good indicator of perinatal and postnatal health . Poor feStudies have examined the relationship between prenatal characteristics and birth outcomes with the mediation effect of favourable fetal growth conditions (FFGC) , 12, 13.FFGC is associated with dimensions that play an essential role in prenatal development such as environmental, genetic or epigenetic factors . Due to A previous study  in DurbaThe Mother and Child in the Environment (MACE) birth cohort is a study with ongoing recruitment in Durban, South Africa. The study enrolled a cohort of 996 pregnant women from March 2013 to May 2017 from public sector antenatal clinics in the study areas. From a total of 996 women, 687 of them were enrolled subjects followed up during their pregnancy, through to labour and delivery, with the remainder having had multiple pregnancies (n = 2); miscarriages (n = 55); still births (n = 25); and termination of pregnancy (n = 2) and were therefore excluded from the cohort. A further 225 participants relocated outside the areas of interest. Excluding 31 participants with postdates birth  reduced the effective sample size to 656 mother-child pairs. This study was developed with data from MACE birth cohort in Durban, South Africa in the period of 2013 to 2017. The inclusion, exclusion criteria of selection of participants is as follows. All pregnant women that were at a gestational age of fewer than 20 weeks and resident for the full duration of the pregnancy in the geographical area within which the clinic was located as well as for the follow-up period of 5–6 years in the cohort were recruited in the study. Women with multiple pregnancies were excluded from the study.2) was calculated using first-trimester weight and height.This study considered both observed and latent variables as prenatal exposure factors. Observed variables include environmental (exposure to NOx pollution), clinical , pre-gestational body mass index (BMIT1), and HIV status (HIV Positive)), maternal age (Mage), and parity (multiparous). Latent variables: diet , physicμg/m3) for participants in the MACE birth cohort was predicted, using land use regression model based on pre-selected geographic predictors, such as land use types, road length, topography, population and housing density with the methodology used in the European Birth Cohorts (ESCAPE). The parameter estimates were used to predict NOx exposure at the residential addresses of the study participants, as detailed in Muttoo et al. 13], and Studies that consider the only birthweight as fetal growth found positive associations of higher maternal pre-gestational BMI and GWG with the risk of larger birthweight of infants –31. Our The strength of this study is the use of the latent variable approach which allows three commonly available birth outcomes BW, BL, and GA as a proxy for the fetal environment instead of using only birthweight on data from a developing country. This provides a very general and convenient framework for statistical analysis that includes several multivariate procedures such as regression analysis, discriminant analysis, and canonical correlation, as special cases. Another strength of our study is the use of maternal exposure risk factors of adverse birth outcomes, such as BMI, exposure to NOx, current and passive smoking habits, alcohol consumption and physical activity during pregnancy. Even “well-behaved” random errors can bias the coefficient estimates of the health effects of not only the fetal environment indicators  but also of the other control variables that are part of the analysis. This happens even if the control variables are free of error . For thiThe main limitation of this study is the use of a single average pollutant NOx exposure levels during the whole pregnancy. The effect of exposure to NOx at different trimesters may have a differential effect on birth outcomes. Another limitation of the study is the absence of the weekly or monthly weight gain measurements. This may have influenced the association with the latent variable and needs to be investigated in other areas with repeated measurement of gestational weight gain.Structural equation modeling allowed an investigation of maternal pre-gestational BMI and gestational weight gain as mediators of prenatal exposures and birth outcomes via FFGC. This methodological approach takes into account the correlation between multiple birth outcomes. Consequently, prenatal behavioural risk exposure was related to severe birth outcomes. Among others, maternal smoking, environmental exposure to smoking and alcohol consumption during pregnancy led to unfavourable fetal growth conditions. Furthermore, high level of mother’s physical exercise was found in the reduction of mothers’ gestational weight gain.


Set1 = 1,395, nSet2 = 362), relating adult DNAm from whole blood to birth weight. Meta-analysis yielded one genome-wide significant CpG site (p = 5.97x10−9), cg00966482. There was minimal evidence for attenuation of the effect sizes for the lead loci upon adjustment for numerous potential confounder variables . Associations between birth weight and epigenetic measures of biological age were also assessed. Associations between lower birth weight and higher Grim Age acceleration (p(FDR) = 3.6x10−3) and shorter DNAm-derived telomere length (p(FDR) = 1.7x10−3) are described, although results for three other epigenetic clocks were null. Our results provide support for an association between birth weight and DNAm both locally at one CpG site, and globally via biological ageing estimates.The Developmental Origins of Health and Disease (DOHaD) theory predicts that prenatal and early life events shape adult health outcomes. Birth weight is a useful indicator of the foetal experience and has been associated with multiple adult health outcomes. DNA methylation (DNAm) is one plausible mechanism behind the relationship of birth weight to adult health. Through data linkage between Generation Scotland and historic Scottish birth cohorts, and birth records held through the NHS Information and Statistics Division, a sample of 1,757 individuals with available birth weight and DNAm data was derived. Epigenome-wide association studies (EWAS) were performed in two independently generated DNAm subgroups (n The Developmental Origins of Health and Disease theory (DOHaD) states that through developmental plasticity, the foetal experience can permanently influence adult health . The theThere is strong, well-replicated evidence for an association between birth weight and adult health. There is particularly consistent evidence for associations between low birth weight and poor cardiovascular outcomes, such as heart disease, type II diabetes, stroke, and hypertension , as wellPrenatal factors affect the foetus in its highly plastic state, giving rise to birth weight variability, and also to developmental changes which permanently affect the function and health of organs and systems . Given t−5 [Birth weight associations with DNAm have been previously described in neonatal blood  and duri−5  but do nIn addition to the stand-alone importance of discovering DNAm associations with birth weight in adults, recent work has revealed the utility of so-called ‘epigenetic clocks’ in demonstrating elements of vulnerability to disease and mortality . These cHere, we report an Epigenome-Wide Association Study (EWAS) of birthweight using whole blood DNA derived in an adult sample, and associations between birth weight and five epigenetic clocks. While previous work has attempted to find persistent DNAm relationships to birth weight from infancy to adulthood ,18, noneThis study was performed on a subgroup of the Generation Scotland (GS) cohort whose birthweight data were collected at parturition in historical cohort studies. Data linkage strategies were employed to ascertain birthweight in grams from those historical cohorts. A subgroup of these individuals for whom DNA methylation data were processed formed the sample for EWAS and epigenetic clock analyses .Figure 1Generation Scotland (GS) is a Scottish family-based cohort n = 23,690 . Data weAll analyses were conducted in R version 3.5.1 .To control for the known effects of gestational age and sex on birthweight , we consThese are referred to as ‘birth weight residuals’ hereafter.Supplementary File 2). Birth weight and gestational age information were available for n = 1,395 of this methylation set . Quality control and normalization were carried out as described elsewhere , creating an independent set of methylation data for an additional 4,450 GS participants. In this replication sample, a further 362 participants with both birth weight and gestational age information were used, hereafter called 'set 2'.The second set of DNAm data used a near identical protocol (Supplementary File 2), as the first batch of DNAm data were collected on related individuals:The birth weight residuals described above were used in the EWAS model, which was run using the ‘limma’ package in R . The set 1 EWAS model used CpGs corrected for relatedness , which were regressed out during the relatedness pre-correction for the set 1 dataset, were also included in the set 2 dataset of unrelated individuals.−8 [EWAS findings are considered epigenome-wide significant if p < 3.6x10−8 .An inverse variance-weighted meta-analysis of the set 1 and set 2 EWASs was performed using the METAL software package. Summary statistics from the set 1, set 2, and meta-analysis EWASs are available at https://doi.org/10.7488/ds/2876.Set1 = 1,346, nSet2 = 351, resulting in a total nMeta = 1,697. By contrast, the full sample discussed in this report comprises both preterm and term born individuals.To account for the possible differences between preterm- and term-born infants, we re-ran the analyses detailed above on a subsample excluding those with gestational age <37 weeks. This is in line with the World Health Organization’s guidelines on preterm birth which states that birth before 37 completed weeks of gestation should be defined as preterm . The totSupplementary File 1. Correction for smoking and 20PCs were already included in the EWAS model. Set 1 DNAm data were pre-corrected for batch, cell counts, and relatedness. The fully-adjusted model was:As a sensitivity analysis, the EWAS meta-analysis was re-examined, fitting additional covariates individually, and together in a fully-adjusted model. Covariates were selected to account for additional lifestyle factors which may associate with DNAm or birth weight. These variables could represent confounding or mediating factors on the relationship between birthweight and adult DNAm. One of these covariates was socioeconomic status as ranked by the postcode-derived Scottish Index of Multiple Deprivation (SIMD). Socioeconomic status is positively associated with birth weight , and hasDetail on the estimation of the five epigenetic clocks used have previously been reported elsewhere . BrieflyAll components of GS received ethical approval from the NHS Tayside Committee on Medical Research Ethics (REC Reference Number: 05/S1401/89). GS has also been granted Research Tissue Bank status by the Tayside Committee on Medical Research Ethics (REC Reference Number: 10/S1402/20), providing generic ethical approval for a wide range of uses within medical research.There were 1,757 Generation Scotland (GS) participants with both birth weight and DNAm information available . The set−8 [−5   that had absolute r ≥ 0.6.The set 1 EWAS of birth weight revealed no CpGs significant at the genome-wide level , altho0966482) ; Supplem−5 significance threshold in the set 1 EWAS, two reached nominal significance (p < 0.05) in the set 2 analysis: cg00590817 (p = 0.0069), and cg00966482 (p = 0.031). The latter CpG was the most significantly associated site from the set 1 EWAS. There was moderate concordance between the effect sizes of the top 19 DNAm associations with birthweight in set 1, and the same CpGs in the set 2 analysis (r = 0.59) (There were no genome-wide significant associations in the set 2 sample (n = 362) ; Supplem = 0.59) .Figure 3HERV-FRD and LOC221710/SMIM13 genes  excluding those with less than 37 complete weeks gestational age at birth (see Supplementary Table 4 for population characteristics). In the meta-analysis EWAS performed in this subgroup, cg00966482 remained significant, with a slightly greater effect . There were 36 CpG sites with p < 1x10−5, 23 of which appeared in the list of 36 lead sites in the main meta-analysis EWAS (Supplementary Table 5).To address the view that preterm births may represent a distinct group, we ran the EWASs on a subgroup . There was, however, good concordance between the effect sizes for the top 36 CpG sites identified in the main model, and the same sites in this fully-adjusted sensitivity model  = 3.6x10−3) and longer DNAm telomere length  = 1.7x10−3; The mean values for the five epigenetic clocks were: Horvath age 44.7 yrs (SD = 10.6); Hannum age 36.1 yrs (SD = 10.2); PhenoAge 32.8 yrs (SD = 12); GrimAge 45.7 yrs (SD = 14.1); DNAm telomere length 7.6 kilobase pairs (SD = 0.29). Linear regression models of birth weight residuals (outcome) against five signatures of epigenetic age acceleration  revealed significant associations between higher birth weight and lower Grim Age acceleration . HERV-FRD encodes syncitin-2, a protein involved in placental embedding, whereas LOC221710/SMIM13 is a gene with unknown functions [−5 in the meta-analysed EWAS, 20 were located within known genes. Eighteen of the 20 sites were within regions with evidence for transcription factor binding, open chromatin, or DNase hypersensitivity. These may be attractive candidates for further investigation of the relationship between birth weight, DNA methylation, and transcriptional activity (Supplementary Table 3). Several of these genes contain SNPs that have genome-wide significant associations (GWAS P < 5x10−8) with cardiovascular, psychiatric, and developmental pathways (Supplementary Table 7). Four of the 36 CpG sites exceeding p < 1x10−5 identified in the meta-analysis EWAS were highly correlated , suggest that future studies might wish to focus on studying this relationship between birth weight and CASZ1 methylation in further detail. Genetic variants in CASZ1 have previously been implicated by GWAS in various aspects of cardiovascular health (Supplementary Table 7). These have included studies in multi-ethnic populations on blood pressure [In the EWAS meta-analysis we observed a genome-wide significant association between higher birthweight and higher methylation levels at cg00966482  as the primary analysis. However, there was an increase in the effect size, resulting in a lower p-value for this CpG (p = 5.68x10−9). There were some differences between the CpGs identified at a suggestive epigenome-wide threshold of p < 1x10−5 . This may indicate differences in the biological pathways associated with birth weight in adults, according to the length of gestation, and would be an interesting topic for further study.Sensitivity analyses that excluded preterm births or adjusted individually and collectively for a series of possible confounder/mediator lifestyle variables resulted in only minor changes to the effect sizes of the primary model. However, the covariate adjustments did result in increased p-values for all CpG sites, suggesting that replication in larger samples and further work to investigate the possibility of mediation by lifestyle factors should be considered. The analysis excluding preterm births identified the same epigenome-wide significant site (cg00966482, Significant associations are demonstrated between birth weight and epigenetic predictors of ageing, mortality, and cellular senescence. Higher birth weight is associated with lower GrimAge acceleration  and longThis study exploited rarely available data linkage capacity to acquire neonatal information from birth medical records. This was then linked to DNAm in a large adult sample. There are, however, some limitations inherent to the design of this study. Longitudinal data would allow analysis of the persistence of DNAm signatures across time, although this has been investigated in previous studies . A furthDNAm data were derived from whole blood taken during adulthood, so our findings might not generalize to other tissue types. However, there are advantages to interrogating blood-based methylation levels: first, it is the only tissue type that is readily available in large epidemiological cohorts; and second, it is systemic and tracks multiple biological processes including biomarkers of inflammation, cardiovascular disease, cardiometabolic disease, all of which are relevant processes related to birthweight.This study presents the first epigenome wide association study of birth weight on DNA methylation in adulthood, alongside associations between birth weight and both epigenetic age acceleration and telomere length. The Developmental Origins of Health and Disease theory predicts that birth weight, which may be seen as a marker of the intrauterine environment, is associated with outcomes in many domains of adult health, and it has been proposed that these associations may be reflected in the epigenome. We found evidence to support this at both the level of single CpG site methylation, and at the level of broader mortality and health-related DNAm phenotypes.Click here for additional data file.


Similarity indices between each joint angle or joint angular velocity did not differ between the two groups in most of the joints at the upper and lower extremities. Quantitative assessments of spontaneous movements in preterm infants are feasible using a deep learning algorithm and sample entropy. The results indicated that complexity indices of joint movements at both the upper and lower extremities can be potential candidates for detecting developmental outcomes in preterm infants.This study aimed to develop quantitative assessments of spontaneous movements in high-risk preterm infants based on a deep learning algorithm. Video images of spontaneous movements were recorded in very preterm infants at the term-equivalent age. The Hammersmith Infant Neurological Examination (HINE) was performed in infants at 4 months of corrected age. Joint positional data were extracted using a pretrained pose-estimation model. Complexity and similarity indices of joint angle and angular velocity in terms of sample entropy and Pearson correlation coefficient were compared between the infants with HINE < 60 and ≥ 60. Video images of spontaneous movements were recorded in 65 preterm infants at term-equivalent age. Complexity indices of joint angles and angular velocities differed between the infants with HINE < 60 and ≥ 60 and correlated positively with HINE scores in most of the joints at the upper and lower extremities ( Early recognition of risks detectable in neonates can facilitate timely intervention and improve neurodevelopmental outcomes of high-risk infants4. Spontaneous movements in infants have been recognized as one of the most important predictors of cerebral palsy at the earliest possible age5. Spontaneous movements which begin in the early fetal period and last until the first 6 months post-term may reflect the integrity of the developing nervous system7. Currently, the General Movement Assessment (GMA) for evaluating spontaneous infantile movements is the validated tool for the early detection of cerebral palsy8 along with neonatal magnetic resonance imaging9 and the Hammersmith Infant Neurological Examination (HINE)10.Identifying high-risk indicators of cerebral palsy in preterm infants is crucial for early detection11. Previous studies have demonstrated that abnormal writhing movements and absent fidgety movements indicate an increased risk for adverse neurodevelopmental outcomes14. Thus, recent literature has recommended GMA for infants under 5 months of corrected age with newborn-detectable risks15. However, GMA for spontaneous movements in infants is conducted in a qualitative or semi-quantitative manner and may depend on skills and experience of the assessors. Certified assessors educated in high-quality training courses are necessary to conduct GMA, which may limit its clinical routine use16. To extend the availability of objective assessments of spontaneous infantile movement, it is important to quantitatively analyze the kinematics of the upper and lower extremities in preterm infants.The GMA is a standardized motor assessment that uses video recordings of spontaneous infantile movements17. Particularly, the vision-based approaches using RGB cameras has been getting great interest with popularization of smartphones and recent advances in pose-estimation models based on deep learning algorithms. This approach can have several advantages compared to methods using direct sensing modalities including relative easiness to understand, high spatial resolution, high context information, non-intrusiveness, not-dependence on reflective markers or inertial sensors, and high availability18.There have been previous attempts to analyze the spontaneous infantile movements based on automatic assessments. The automatic assessments can be helpful to reduce reliance on assessors, thereby decreasing human error. The sensing modalities of the automatic assessments in previous studies can be categorized into indirect sensing, where hardware is placed around the assessment environment  and direct sensing, where movements are captured using hardware attached to bodies 19. To acquire data by tracking the location of the specific body structures, a motion tracking system using reflective markers21 were used and much simple methods using a single RGB camera have been adopted in recent studies25. This can be attributed to the progress of automatic pose-estimation techniques for two-dimensional image data and their disclosure as open source models including OpenPose26 and AlphaPose27. The previous studies have usually aimed to establish methods to quantify and classify spontaneous infantile movements28 or to develop prediction models to estimate developmental delay or cerebral palsy20. Although the classification or prediction performance of the previous models was relatively satisfactory, these models may provide information based on engineering techniques that can be unfamiliar or not be straightforward to clinicians to interpret and utilize for clinical decision-making. Clinicians may require more easily interpretable results based on quantitative assessments of important spatiotemporal variables.Previous researches using vision-based approaches have been steadily published for the past two decadesTherefore, this study aimed to develop automatic standardized methods for quantitatively analyzing spontaneous movements in preterm infants and to analyze spontaneous movements according to early neurological development based on established quantitative assessments.From March 2019 to January 2020, preterm infants with gestational age < 32 weeks or birth weight < 1500 g admitted to the neonatal intensive care units of two tertiary hospitals were enrolled in this study. Infants were excluded if they had genetic syndromes, major congenital malformations, or medically unstable conditions, such as requiring cardiovascular support, active sepsis, or any major surgery that could affect the spontaneous infantile movements. Informed consent was obtained from parents or legal guardians of all infants according to the institutional guidelines. After discharge, the participants entered the standard follow-up programs, including pediatric and neurologic evaluations and parental educational support. The study was approved by the institutional review boards of Seoul National University Hospital and Chung-Ang University Hospital. It was performed in accordance with all relevant guidelines and regulations.29, antenatal steroid use, periventricular leukomalacia, intraventricular hemorrhage, period of invasive ventilator use, patent ductus arteriosus, treatments of patent ductus arteriosus, retinopathy of prematurity, history of sepsis, and history of seizure; and maternal characteristics: maternal preeclampsia, gestational diabetes mellitus, multiple gestations, and maternal chorioamnionitis. Categories of GMA were determined by one certified expert who were blinded to the clinical history of the infants. Brain magnetic resonance imaging at term-equivalent age was performed in infants with birth weight < 1000 g, gestational age < 29 weeks, or those with severe intraventricular hemorrhage on brain ultrasonography.Clinical information of the infants at the perinatal and postnatal periods was obtained including infantile characteristics: sex, gestational age, postnatal age, birth weight, global score of HINE, corrected age at HINE, categories of GMA; neonatal morbidities: 1- and 5-min Apgar scores, bronchopulmonary dysplasia severity8. The instructions for making video recordings of spontaneous movements in this study were as follows: infants are (1) lying supine, naked, fully awakened, but without agitation, such as crying or fussing; (2) in a comfortable, quiet, and undisturbed condition at a neutral temperature; (3) free to move their bodies and all limbs including the fingers and toes, which are included in the recording scenes; and (4) recorded using a conventional or smartphone RGB camera31 for 3–5 min with at least 2 continuous min recorded by a research assistant with a certificate in occupational therapy or the parents. In cases of discharge from the hospital before the term-equivalent age, the parents were requested to record and transmit videos of their infants at home to the research team using their smartphone camera. The process of video recordings and transmission was explained to the parents or legal guardians before and after hospital discharge. If the recorded videos were considered unsuitable according to the instructions, recordings were conducted again within the period of term-equivalent age. The recorded videos were edited and combined into 3–5-min sequences.Video images of spontaneous movements in preterm infants were recorded according to the standard protocol of GMA at term-equivalent age 27. It can produce positional coordinates of each joint with confidence levels from 0 to 1 at each frame. The positional coordinates with confidence levels < 0.5 were regarded as measurement errors and eliminated from the positional data. Joint angles and joint angular velocities were determined as basic data in further kinematic analyses because these parameters are less susceptible to differences in camera distance from or angle of viewing of the infants compared to positional coordinates per se or the length between adjacent joints. The joint angle was defined as the angle formed by the positional coordinates of the corresponding joint and its two adjacent joints , a measure of the degree of signal regularity for time-series data as a complexity index33. Sample entropy is a measure of the degree of signal regularity, complexity, or ensemble orderliness for time-series data34. Reduced complexity in terms of sample entropy indicates that time-series data of joint angles and angular velocities are relatively more regular, less random, and less complex. Inter- and intra-limb synchronization of joint angles and joint angular velocities were quantified using Pearson correlation coefficients. These are measures of dependence between two paired data points with linear association and were used as a similarity index. It can reflect simultaneous changes of joint angles or joint angular velocities among bilateral upper and lower limbs: the joint angles and joint angular velocities of shoulders, elbows, hips, and knees at the right and left sides.After preprocessing of time-series data of joint angles and joint angular velocities, the maximum, minimum, mean, and standard deviation values were calculated for each infant. Inter-limb synchronization and complexity during spontaneous movements were investigated with kinematic analysis since these are hallmarks of brain dysfunction and are associated with developmental disorders36. Global scores < 56 at 3 months of corrected age are considered highly indicative of cerebral palsy, and it is widely accepted that HINE scores of 40–60 at 3–6 months of corrected age indicate gross motor function classification system scores I–II37. Considering this information, the study participants were divided into the following two groups according to the HINE scores: HINE < 60 and ≥ 60.The HINE was utilized to assess neurological outcomes in infants at 4 months of corrected age. The HINE was evaluated by an experienced physiatrist or physical therapist and was blinded to the infants’ medical histories. The HINE comprises five sections of examinations including assessments of cranial nerve function, posture, movements, tone, and reflexes and reactions with scores ranging from 0 to 78. The five sections were evaluated separately and then added to obtain the global scores. The global score at the corrected age of 3–4 months ranges from 62.5 to 69U test for continuous variables and chi-squared test or Fisher’s exact test for categorical variables. Pearson correlation coefficients were obtained to analyze the correlations between HINE scores and complexity indices for joint angles and joint angular velocities. The complexity and similarity indices for joint angles and joint angular velocities were compared between the HINE < 60 and ≥ 60 groups using Student’s t test or Mann–Whitney U test. The significance level was set at p < 0.05. The statistical analyses were conducted using SPSS software . Complexity indices were calculated using R version 3.5.1  with the pracma package.The clinical characteristics were compared between infants with HINE < 60 and those with HINE ≥ 60 using Mann–Whitney p = 0.002) and patent ductus arteriosus (p = 0.040).In total, 65 infants who fulfilled the inclusion criteria were enrolled. Table p = 0.009; 70.01 [29.66] vs. 90.91 [27.1], p = 0.011) and standard deviation of joint angles at the right and left shoulders  differed significantly between the infants with HINE < 60 and ≥ 60. The maximum, minimum, and standard deviation of joint angular velocities at the right shoulder differed significantly between the two groups . The mean values of joint angular velocities at the right hip and knee differed significantly between the two groups . The standard deviation in joint angular velocities at the right elbow, right knee, and left knee differed significantly between the two groups .Illustrations of joint angles and joint angular velocities at the bilateral shoulders, elbows, hips, and knees are shown in Fig. The complexity indices of joint angles and angular velocities had significant positive correlations with HINE scores in most of the joints at the upper and lower extremities within the range of 0.2–0.4 Table .Table 2Rp = 0.016), left shoulder and elbow , and left shoulder and hip  differed significantly between the infants with HINE < 60 and ≥ 60. There was no significant difference in the correlation coefficients among joint angular velocities between the two groups.Joint angles and angular velocities indicated very weak or weak correlations in most of the joints at the upper and lower extremities, except for the ipsilateral hip and knee joints, which showed strong or very strong correlations  during brain development; this may induce movement complexity40. One of the characteristics in deviant patterns of the spontaneous movements is a lack of variability; this can result from injuries or dysfunction of the subplate or cortical plate and/or its connective fibres41.In this study, reduced complexity of spontaneous movements was significant or demonstrated a trend towards significance for all of the upper and lower extremities in the preterm infants with early neurological development. Global scores of HINE at 3–6 months of corrected age are significantly associated with levels of Gross Motor Function Classification System in cerebral palsy and cognition at 2 years of age in previous studies41. SE was adopted as a key index to measure complexity quantitatively. Generally, reduced complexity indicates fetal or neonatal compromise and has been regarded as one of the important characteristics to distinguish normal and abnormal spontaneous movements during the writhing period43. A previous study demonstrated that SE of time-series kinematic data acquired from infants with inertial sensors attached to the lower extremities is associated with a risk of developmental delay33. In that study, SE of the lower-limb movements was significantly decreased in the infants at risk of developmental delay, which is consistent with the results of the current study. Conversely, similarity in terms of the Pearson correlation coefficients did not correspond with the results of complexity. It may be assumed that the similarity of the inter- or intra-limb movements reflects the characteristics of cramped-synchronized movements, but the similarity index, in terms of Pearson’s correlation coefficients, may be insufficient to discriminate infants according to the early neurological development. It is necessary to plan future studies that reveal the quantitative features of each type of spontaneous movements according to GMA.Complexity, which comprises spatial and temporal variability, was investigated to objectively measure spontaneous movements in preterm infants since reduced complexity is strongly associated with cerebral palsy17. One of the main approaches applied is a two-dimensional video-based approach. This has been strengthened by the rapid progress of computer vision technologies, such as deep learning algorithms, and the popularization of smartphone cameras19. In the current study, AlphaPose, an open-source pose-estimation model that demonstrates state-of-the-art performance, was used to extract the positional coordinates of each joint at the upper and lower extremities27. The acquisition of positional coordinates was conducted automatically using AlphaPose, facilitating the efficient performance of kinematic analyses of spontaneous infantile movements. The pose-estimation model provides automatic acquisition of spatiotemporal data on the trunk, arms, and legs of infants without labour-intensive and time-consuming manual marking. This study determined the kinematic parameters as joint angles and joint angular velocities, rather than as the raw data of the positional coordinates. Joint angles were considered beneficial since they can be less affected by the camera’s height, tilt/roll angles, and directions compared to positional coordinates and be straightforward for clinicians to analyze46.Automatic computer-based analyses of spontaneous infantile movements have been explored for clinical use in numerous previous studiesThis study has several limitations. First, in this study, a neurological outcome in infants was the global score of HINE at 4 months of corrected age. Even though a low global score of HINE at an early stage is suggestive of developmental delay or cerebral palsy, future studies are necessary to identify the long-term longitudinal association between complexity indices of spontaneous infantile movements and poor neurological outcomes. Second, the sample size of this study was relatively small and a further study is warranted with a large population of preterm infants. Third, kinematic analyses were performed on the two-dimensional video images, not on the three-dimensional image analyses of spontaneous movements in preterm infants. To obtain easy access to video images of the infants after hospital discharge, this study adopted the image acquisition instruments of conventional or smartphone RGB cameras.In conclusion, quantitative assessments of spontaneous movements in preterm infants using a deep learning algorithm and sample entropy are feasible. Complexity indices in terms of SE of joint angles and joint angular velocities at both the upper and lower extremities are associated with early neurological development. This study indicates that complexity indices of spontaneous movements can be potential candidates to detect cerebral palsy in high-risk infants. Further studies are warranted with larger cohorts of preterm infants and a focus on developing automatic computer-based models using complexity indices for predicting developmental outcomes in clinical practice.Supplementary Information 1.Supplementary Information 2.Supplementary Information 3.Supplementary Information 4.