Nemaline myopathy: a clinical study of 143 cases

We report 143 Australian and North American cases of primary nemaline myopathy. As classified by the European Neuromuscular Centre guidelines, 23 patients had severe congenital, 29 intermediate congenital, 66 typical congenital, 19 childhood-onset, and 6 adult-onset nemaline myopathy. Inheritance was autosomal recessive in 29 patients, autosomal dominant in 41, sporadic in 72, and indeterminate in 1. Twenty-two patients had skeletal muscle actin mutations and 4 had mutations in the alpha-tropomyosin(slow) gene. Obstetric complications occurred in 49 cases. Seventy-five patients had significant respiratory disease during the first year of life, and 79 had feeding difficulties. Atypical features in a minority of cases included arthrogryposis, central nervous system involvement, and congenital fractures. Progressive distal weakness developed in a minority of patients. Thirty patients died, the majority during the first 12 months of life. All deaths were due to respiratory insufficiency, which was frequently underrecognized in older patients. Arthrogryposis, neonatal respiratory failure, and failure to achieve early motor milestones were associated with early mortality. Morbidity from respiratory tract infections and feeding difficulties frequently diminished with increasing age. Aggressive early management is warranted in most cases of congenital nemaline myopathy.

Anterior horn cell disease and olivopontocerebellar hypoplasia

To date, fewer than 30 cases of anterior horn cell disease with associated olivopontocerebellar hypoplasia have been reported. We describe five patients and review the literature on this uncommon disorder. In addition to a syndrome of progressive spinal muscular atrophy similar to that seen in Werdnig-Hoffmann disease, this disorder is characterised by hypoplasia of the olivary nuclei, pons, and cerebellum. Additional clinical features may include dysmorphism, abnormal eye movements, stridor, congenital joint contractures, and enlarged kidneys. Pontocerebellar hypoplasia may be associated with posterior fossa cystic malformations, cerebral atrophy, and a demyelinating neuropathy.

Childhood chronic inflammatory demyelinating polyneuropathy: clinical course and long-term outcome

We reviewed the clinical history, electrophysiologic and pathologic findings, and response to therapy of 16 children with chronic inflammatory demyelinating polyneuropathy. The majority presented with lower limb weakness. Sensory loss was uncommon. The illness was monophasic in seven children, relapsing in six, and three had a slowly progressive course. All patients were treated with immunosuppressive agents. In 11, the initial treatment was prednisolone. All had at least a short-term response but five went on to develop a relapsing course. Intravenous immunoglobulin was the initial treatment in four patients. Three responded rapidly, with treatment being stopped after a maximum of 5 months. In resistant chronic inflammatory demyelinating neuropathy, in addition to prednisolone and immunoglobulin, plasma exchange, azathioprine, cyclosporine, methotrexate, cyclophosphamide and pulse methylprednisolone were tried at different times in different patients. On serial neurophysiologic testing slowing of nerve conduction persisted for long periods after clinical recovery. Follow-up was for an average of 10 years. When last seen 14 patients were asymptomatic, two having mild residual deficits. Childhood chronic inflammatory demyelinating neuropathy responds to conventional treatment and generally has a favourable long-term outcome.

Persistent or severe back pain and stiffness are ominous symptoms requiring prompt attention

BACKGROUND

Children with severe or persistent back pain and stiffness often have an underlying organic cause but there is a large differential diagnosis, examination may be difficult and the problem is relatively rare in general paediatric practice. These difficulties appeared to lead to delays in diagnosis and management of children with this problem.

OBJECTIVES

To provide an approach to the diagnosis and management children with severe or persistent back pain or stiffness based on our clinical experience and the literature.

METHODOLOGY

The case histories of 10 children with severe back pain seen by the authors over a 5-year period were reviewed. They were chosen as illustrative examples of the diagnostic and management problems and did not represent a systematic review of all cases seen by the authors over that time.

RESULTS

Underlying causes included infection, inflammation, neoplasm, trauma and vascular malformation. Four of the children had spinal cord compression which required urgent decompression. There was one child with a conversion disorder but three children with organic disease were initially felt to have a conversion disorder. Investigations generally proceeded relatively slowly and the problem was not regarded as a semi-urgent situation carrying the risk of permanent paraplegia. Magnetic resonance imaging (MRI) scan of the spine was the investigation of choice.

CONCLUSION

Children with severe or persistent back pain and stiffness have a wide variety of underlying causes. The possibility of underlying spinal cord compression should always be considered in children with this presentation. If the diagnosis is not obvious, MRI scan of the spine should be arranged without delay.

Cerebral vasculitis in a case of Sydenham's chorea

A 10-year-old girl with acute-onset hemichorea had multiple areas of abnormal signal seen on magnetic resonance imaging of the brain, associated with middle and anterior cerebral artery vasculitis seen on cerebral angiography. Her serology and clinical course were supportive of the diagnosis of Sydenham's chorea. Other causes of cerebral vasculitis were excluded. Follow-up studies revealed resolution of changes seen on magnetic resonance imaging and partial resolution of angiographic abnormalities. This is the first report of abnormal cerebral angiography in Sydenham's chorea.

Influenza A encephalitis with movement disorder

Influenza A is an uncommon but well-recognized cause of viral encephalitis in childhood, occurring most commonly during community influenza outbreaks. The authors report four cases of influenza A encephalitis that occurred during an Australian epidemic in 1997-1998. Choreoathetosis during the acute phase of infection or basal ganglia involvement on neuroimaging was observed in three of the four patients. These findings in pediatric encephalitis are suggestive of influenza A infection and may guide investigation and early diagnosis.

Coordination of two-joint rectus femoris and hamstrings during the swing phase of human walking and running

It has been hypothesized previously that because a strong correlation was found between the difference in electromyographic activity (EMG) of rectus femoris (RF) and hamstrings (HA; EMG(RF)-EMG(HA)) and the difference in the resultant moments at the knee and hip (Mk-Mh) during exertion of external forces on the ground by the leg, input from skin receptors of the foot may play an important role in the control of the distribution of the resultant moments between the knee and hip by modulating activation of the two-joint RF and HA. In the present study, we examined the coordination of RF and HA during the swing phase of walking and running at different speeds, where activity of foot mechanoreceptors is not modulated by an external force. Four subjects walked at speeds of 1.8 m/s and 2.7 m/s and ran at speeds of 2.7 m/s and 3.6 m/s on a motor-driven treadmill. Surface EMG of RF, semimembranosus (SM), and long head of biceps femoris (BF) and coordinates of the four leg joints were recorded. An inverse dynamics analysis was used to calculate the resultant moments at the ankle, knee, and hip during the swing phase. EMG signals were rectified and low-pass filtered to obtain linear envelopes and then shifted in time to account for electromechanical delay between EMG and joint moments. During walking and running at all studied speeds, mean EMG envelope values of RF were statistically (P<0.05) higher in the first half of the swing (or at hip flexion/knee extension combinations of joint moments) than in the second half (or at hip extension/knee flexion combinations of joint moments). Mean EMG values of BF and SM were higher (P<0.05) in the second half of the swing than in the first half. EMG and joint moment peaks were substantially higher (P<0.05) in the swing phase of walking at 2.7 m/s than during the swing phase of running at the same speed. Correlation coefficients calculated between the differences (EMG(RF)-EMG(HA)) and (Mk-Mh), taken every 1% of the swing phase, were higher than 0.90 for all speeds of walking and running. Since the close relationship between EMG and joint moments was obtained in the absence of an external force applied to the foot, it was suggested that the observed coordination of RF and HA can be regulated without a stance-specific modulation of cutaneous afferent input from the foot. The functional role of the observed coordination of RF and HA was suggested to reduce muscle fatigue.

Hysterectomy: social and psychosexual aspects

Studies of the psychological and sexual outcome of hysterectomy have often arrived at conflicting conclusions and this has resulted in some confusion among health professionals as well as among women themselves. This situation should cause concern, since the incidence of this surgery is high in most countries of the western world. The confusion about outcome arises out of the methodological problems that plagued earlier research. Some of the more recent studies using prospective design, standardized measures and appropriate statistical analysis have not implicated hysterectomy with increased psychological or sexual disorders. However, both before and after hysterectomy in samples studied, the rate of psychological disorder was higher than would have been expected in a normal population, although a clearer picture has emerged from the most recent study. In this paper, risk factors are identified, and the need to include women's own evaluation of the procedure is emphasized.

Antenatal HIV antibody testing in Australia

OBJECTIVE

To evaluate the role of voluntary antenatal testing in HIV surveillance and prevention by examining antenatal HIV antibody testing practice and policy in Australia.

DESIGN

Cross-sectional study using a self-administered questionnaire.

SUBJECTS AND SETTING

Specialist obstetricians and gynaecologists and general practitioners (GPs) affiliated with the Royal Australian College of Obstetricians and Gynaecologists and Australian public hospital antenatal clinics, August-November 1992.

MAIN OUTCOME MEASURES

The percentage of public hospital antenatal clinics and specialist and GP obstetricians in Australia who tested pregnant women for HIV antibody as part of their antenatal care, and the proportion of pregnant women in Australia who had an antenatal HIV antibody test in the 1991-92 financial year.

RESULTS

Questionnaires concerning antenatal HIV antibody testing were completed by 90% (993/1108) of specialists, 87% (2134/2461) of GPs and 93% (215/230) of public hospitals surveyed. Of the 706 specialists and 1503 GPs who reported that they were currently engaged in obstetric care, approximately 60% (430/706) and 935/1503, respectively) offered antenatal HIV testing either to all pregnant women or to selected groups at risk. There were significant differences in testing patterns between States and Territories. For the 95 public hospitals with antenatal clinics, 81% (77) offered the HIV antibody test to all or selected groups of pregnant women; these percentages did not differ significantly between States and Territories. It was estimated that 25% of pregnant women seen by specialists, 29% seen by GPs and 9% seen in public hospital clinics were tested for HIV antibody as part of their antenatal care in 1991-92.

CONCLUSIONS

In Australia approximately one in five pregnant women were tested for HIV antibody as part of their antenatal care in 1991-92. Voluntary HIV testing in pregnancy may provide unrepresentative data for measuring the prevalence of HIV infection in pregnant women.

The polyurethane nasotracheal tube

An uncuffed nasotracheal tube for use in minor maxillofacial surgery has been developed using polyurethane. The suitability of this tube as an alternative to the existing soft red rubber and harder polyvinyl chloride materials has been assessed at four centres during anaesthesia for routine oral surgery. The tube was found to be satisfactory.

Communication development in Angelman's syndrome

The communication development in 11 children with Angelman's syndrome is described. The clinical observation that these children appear to have a greater ability with receptive rather than expressive language is investigated and these skills assessed using published communication schedules. In addition the understanding and the use of nonverbal communication such as natural gesture was studied. The data collected highlight the fact that these children have developed very few words and have difficulty in using gestural or sign systems. This has implications for speech and language therapists and the children's remedial programmes. Possible future longitudinal studies are suggested.

Reproductive health: knowledge, attitudes and needs of adolescents

OBJECTIVE

To determine the knowledge and attitudes of adolescents with respect to reproductive health, with particular emphasis on their knowledge of the symptoms and transmission of sexually transmitted diseases (STDs), preventive strategies and sources of information.

DESIGN

Questionnaire survey of a stratified random sample of Year 10 students followed by group interviews with volunteers from the sample.

SETTING

The study was carried out in 33 Victorian secondary schools.

PARTICIPANTS

The questionnaire was administered to a stratified random sample of 1351 Year 10 students. Group interviews were conducted with 533 volunteers from the sample.

MEASUREMENTS AND MAIN RESULTS

Considerable gaps were identified in knowledge of STDs and their short-term and long-term effects on reproductive health. An STD Knowledge Score was constructed based on responses to 46 items. The mean score for the full sample was 22.7 (49.3% correct) with a standard deviation of 6.4. As a group, country students scored better than city students (mean, 23.8 v. 22.2, t = 3.97, P less than 0.001) and females better than males (mean, 23.5 v. 21.9, t = 4.21, P less than 0.001). Medical practitioners were rarely identified as a source of preventive advice.

CONCLUSION

The deficiencies identified in knowledge about reproductive health suggest that young people need better access to health information. Schools and the medical profession need to work together both to provide information and to help young people develop the confidence to use available information sources.

Selective improvement in cognitive test scores of extremely low birthweight infants aged between 2 and 5 years

The cognitive development at 2 and 5 years of a cohort of extremely low birthweight (ELBW) children (birthweight 500-999 g) was compared with that of cohorts of larger very low birthweight (VLBW) children (birthweight 1000-1500 g) and normal birthweight (NBW) children (birthweight greater than 2500 g) to determine whether the improvements in cognitive function of ELBW infants between 2 and 5 years are apparent or real. At 2 years of age, ELBW children had a mean Mental Developmental Index (MDI) on the Bayley Scales of 90.4, significantly lower than the means of 100.3 for the larger VLBW children (P = 0.006), and 107.8 for the NBW children (P = 0.0002). However by 5 years the mean scores on the Wechsler Preschool and Primary Scales of Intelligence (WPPSI) full-scale for the ELBW and larger VLBW children were virtually identical (105.9 and 106.0 respectively)--but still lower than the mean WPPSI full-scale of 114.6 for the NBW children. After standardizing the MDI and WPPSI scores relative to the NBW children, the ELBW children improved between 2 and 5 years (paired t-test, t = 3.2, P = 0.004) whereas the larger VLBW infants did not. We postulate that ELBW children require more time than larger VLBW children after birth to compensate for perinatal and other stresses, and that developmental delay at 2 years may not always persist to 5 years.

Psychological aspects of hysterectomy. A prospective study

Sixty women aged between 30 and 55 years, having hysterectomy for benign conditions, were prospectively studied to investigate psychological adjustment to operation, and to explore social, psychological and physical factors associated with psychological outcome. A further 30 women were included for prospective research on psychological outcome. Investigations took place within two weeks of operation and after four months and 14 months. The findings indicated a high prevalence of pre-operative psychological morbidity (55%), which reduced to 31.7% afterwards. There was no evidence that hysterectomy led to a greater psychological distress. The principal risk factors of poor psychological outcome were the previous scores on the mental health measures and personality inventory. Involvement in the research process did not appear to affect psychological outcome.

Accelerated extractable studies of borosilicate glass containers

This article describes the use of an accelerated extractable procedure for borosilicate glass containers. The procedure, which is very similar to a protocol developed by a PDA Task Force, includes the monitoring of Si, Na, K, Al, Ba, Ca, Mg, Fe, and Zn in the extracts as well as measurements of pH change and total extractables. Unlike the PDA protocol, which uses H2O as the sole extraction solution, the procedure outlined in this report used a variety of unbuffered (pH congruent to 4, H2O, pH congruent to 6.5, pH congruent to 8.0, pH congruent to 9.5, and pH congruent to 10.4) and buffered (pH = 8 and pH = 10) aqueous extraction media. Studies were completed for several borosilicate glasses, including a mixture of tubing vials, molded vials, and ampoules from US and European suppliers. Results of these studies are presented in this article and are discussed in terms of the interactions between borosilicate glasses and aqueous solutions.

Diabetes in Western Australian children: descriptive epidemiology

The prevalence and incidence of diabetes mellitus in the age group zero to 14 years in Western Australia were determined from a survey by means of Schools Health Services. Additional information from the State's computer-linked hospital records system, the State's only children's hospital, diabetic clinics and physicians enabled virtually complete ascertainment of cases of childhood diabetes. Only 60% of school-age diabetic children were known to school nurses before the survey, but the nurses were able to identify two-thirds of the remainder during the survey. Among non-Aboriginal children, the prevalence of diabetes in the age group zero to 14 years was 0.59 per 1000 children and the incidence was 12.3 per 100,000 children per year. These rates are somewhat lower than those that have been reported from the United Kingdom and North America, and substantially lower than the rates that were reported from Scandinavia. All but one of the diabetic children who were identified required insulin and were assumed to be insulin-dependent. An excess of boys was found. None of 8715 Aboriginal or part-Aboriginal children had insulin-dependent diabetes mellitus, which indicates that this racial group has a low prevalence of this condition. In case--control studies, which used questionnaires for parents, no significant trends were found in relation to the history of immunizations or of specific viral illnesses except for a past history of varicella which was less frequent in diabetic children. A past history of established breast-feeding (of more than one week) was less frequent in diabetic children, as was the ingestion of vitamin C supplements before the onset of diabetes. Some evidence for a seasonality of onset was obtained. The diabetic children were absent from school for more days and had more admissions to hospital than did non-diabetic children. The majority of diabetic children were prescribed insulin twice a day or more often (84%); performed home blood-glucose monitoring (74%); and attended hospital diabetic clinics (91%).

Longitudinal study of very low birthweight infants: intelligence and aspects of school progress at 14 years of age

Consecutive surviving children weighing less than 1501 g when born in 1966-70 were followed prospectively: 87% (146/168) attended normal secondary schools, 4% (7/168) attended schools for those with special needs and 9% (15/168) were untraced. The psychologist assessed 140 children at a mean age of 14.5 years. The mean WISC-R Verbal Score of 89.7 was almost identical to that achieved by the children at 8 years of age (89.2). Thirty three children (24%) had delay in Reading Accuracy on the Neale Analysis of Reading Ability, whilst 66 children (48%) were delayed on the Comprehension Scale. Social class and duration of maternal education were significant predictors of the WISC-R Verbal Scores and Reading Comprehension at 14.5 years but the total variance explained was small. The Bayley Development Index (MDI) available for half of the children at 2 years often underestimated their potential as defined by the WISC-R Verbal Score at 14.5 years. The 8 year intelligence (WISC-R) and reading measures (Neale) were significantly and highly associated with the corresponding measures at 14.5 years. It was concluded that 8 years was an appropriate age to evaluate the outcome of the children and to identify many of those needing educational intervention. The spasmodic nature and sometimes short duration of the help received by many of the children underlines the need for more appropriate intervention for children with learning difficulties.

Longitudinal study of very low birthweight infants: impairments, health and distance growth to 14 years of age

Of 456 consecutive infants born in a tertiary maternity centre in 1966-70 and of birthweight under 1501 g, 171 (37.5%) survived their primary hospitalization. Subsequently three children died and the outcome of 142 (90.5%) of the remaining children presumably still alive were reviewed at a mean age of 14.5 years. Four children had cerebral palsy although only one child was legally blind, 31.6% (48/152) had an existing or corrected visual impairment; visual impairments occurred significantly more frequently in those of birthweight under 1251 g or those born before 29 weeks gestation. Six children required hearing aids and three others were still epileptic. Four children were chronic asthmatics and one had rheumatoid arthritis. None had disabling malformations and there was no delay in pubertal changes. The distributions of weight, height and head circumference percentiles were not significantly different from a standard Australian population. For children in the cohort, weights and heights were under the 10th percentile in 13.4% and 14.1%, respectively. Of the 30 children with birthweights under the 10th percentile and who were reviewed as teenagers, only eight (26.7%) were still in this weight category.

Children of birth weight less than 1000 g: changing outcome between ages 2 and 5 years

Of 55 consecutive long-term survivors of birth weight 500 to 999 g, complete psychologic and pediatric data were available for 54 children at 2 years corrected age and for 50 at age at least 5 1/2 years. At the latter age, 60% (30 of 50) were not impaired, 10% (five of 50) had severe sensorineural or intellectual impairments, 10% (five of 50) had mild to moderately impairment, and 20% (10 of 50) had minor neurobehavioural abnormalities. Sensorineural deafness in one child and bilateral blindness in one remained stable over time, but of six children with spastic cerebral palsy at 2 years, only three retained this diagnosis at 5 1/2 years. The mean Mental Developmental Index (MDI) on the Bayley Scales at 2 years was 91.1, significantly below the test mean; by 5 1/2 years the mean full scale of the Wechsler Preschool and Primary Scales of Intelligence (WPPSI) was 101.8. The MDI correlated highly with the full-scale WPPSI (r = 0.7), but for individual children it was not always an accurate predictor of 5-year ability. Between 2 and 5 1/2 years there was a substantial reordering within four categories of impairment: findings in 27 children were improved, four were judged to become more severely impaired over time, and 19 did not change. We conclude that our 2-year assessment often underrated the potential of the children as expressed at 5 1/2 years, and that 2 years is too early for reliable classification of children of birth weight 500 to 999 g.

Cerebral palsy in very low birthweight infants surviving to 2 years with modern perinatal intensive care

The rate of cerebral palsy and factors associated with its occurrence were determined in surviving 2-year-old very low birthweight (VLBW) infants born during an era of modern perinatal intensive care. Of the survivors, 12.5% (52/416) of those traced had spastic cerebral palsy. Motor handicaps were mild in 42%, moderate in 25%, and severe in 33% of children with cerebral palsy. The prevalence of cerebral palsy was similar in all birthweight groups up to the upper limit of 1500 gm, and was considerably higher than in survivors born in the same hospital a decade earlier. Although several perinatal variables were associated with the occurrence of cerebral palsy, either singly or in combination, little statistical or clinical confidence would be placed in these associations. Moreover, although 77% of children with cerebral palsy had one or more commonly recognized perinatal risk factors, almost identical rates of risk factors were present in normal children. The advent of cranial ultrasonography during the time of the study was associated with an increase in mortality but no effect on the prevalence of cerebral palsy. Cerebroventricular hemorrhage correlated poorly with the presence of cerebral palsy. The prevalence of cerebral palsy in surviving VLBW infants is unacceptably high; however, no obvious preventable factors in its etiology could be identified.

Improved outcome to two years of very low-birthweight infants: fact or artifact?

In 1966-70, the survival rate for very low-birthweight (VLBW) children born in a tertiary perinatal centre was 37.1 per cent but by 1980-82 it had increased to 68.3 per cent. The latter cohort had a significantly reduced prevalence of strabismus, myopia and a head circumference under the 10th percentile, but a significantly increased prevalence of cerebral palsy compared with the 1966-70 VLBW children. Survivors born in 1980-82 had a significantly increased mean Mental Development Index (MDI) on the Bayley Scales compared with the sub-group of survivors born in 1968-70 but there was also a significant improvement in mean MDI over time for a group of normal-birthweight children. No improvement of MDI scores of VLBW survivors in the 1980-82 cohort could be attributed solely to perinatal care. The two-year-old VLBW children in the 1980-82 cohort had similar rates of sensorineural impairments, disabilities and mean MDI to those who would have survived with the care available in 1966-70. It is concluded that survival of VLBW infants has improved in recent times but that neurodevelopmental outcome still lags behind that of normal-birthweight peers.

Very low birthweight and normal birthweight infants. A comparison of continuing morbidity

One hundred and forty-eight (95.5%) of 155 consecutive two-year survivors of 227 very low birthweight (VLBW, less than 1501 g) infants and 50 (83.3%) of 60 infants of normal birthweight who were selected at random, all of whom were born at the Royal Women's Hospital, Melbourne from October 1980 to March 1982, were seen at the age of two years. Social, psychological and health data were compared between the groups. The mean Bayley Mental Developmental Index scores of VLBW children were significantly lower; the prevalence of major handicaps and poor growth (height and weight below the 10th percentile), and the number of hospital readmissions, wheezing episodes, major and minor congenital anomalies and postnatally-acquired malformations (for example, abnormally shaped skull) were significantly greater in VLBW children. There was a trend for a greater number of episodes of otitis media, lower respiratory tract infections and surgical procedures per child in VLBW children. Extremely low birthweight children (birthweight less than 1000 g) contributed significantly to this morbidity. Parents of VLBW children perceived significantly more problems with infant vomiting and behavioural disturbances at two years of age. The children of mothers of limited education, or immigrant status and non-fee paying or lower socioeconomic families had lower mean Bayley Mental Developmental Index scores but similar handicap rates and health status in both weight cohorts.

Relationship of growth and psychoneurologic status of 2-year-old children of birthweight 500-999 g

There were 257 liveborn infants of birthweight 500-999 g born in one tertiary centre in the 5 1/4 years commencing January 1977; 86 (33.5%) survived to 2 years of age, corrected for prematurity and 83/86 (96.5%) were fully assessed. The prevalence of cerebral palsy was 10/83 (12%) and 17/83 (20%) had a major impairment. The distribution of weights and heights for 2-year-old boys and girls was significantly lower than for the standard population, as was the head circumference distribution for boys; the distribution of the Mental Developmental Index (Bayley Scales) was not related to the head circumference or body weight at two years or to head-circumference/bodyweight or height ratios. At birth measurements of weight, length and head circumference were under the 3rd percentile for 13/86 (15%), 9/86 (10.5%) and 9/86 (10.5%) respectively. By 2 years of age, weight, length and head circumference were under the 3rd percentile in 23/83 (27.7%), 26/83 (31.3%) and 4/83 (4.8%) respectively. 12 children who were SGA at birth were fully assessed at 2 years; the group of 6, who continued with poor postnatal weight gains (under the 3rd percentile) had the highest rate of major impairment but included were the only extremely SGA twins and the only two major malformations in the study. We found no association of other health problems or unfavourable social factors with poor postnatal growth or impaired outcome.

Effects of antenatal steroid therapy on mortality and morbidity in very low birth weight infants

A cohort of 678 consecutive very low birth weight infants, liveborn in one tertiary institution during a 63-month period, was studied to investigate whether antenatal steroid therapy had any beneficial or harmful effects on mortality or morbidity over the first 2 years of life. Comparing the 244 babies who received treatment with the 434 controls, 195 (79.9%) and 265 (61.1%), respectively, were discharged home (P less than 0.001). Mortality in the treated group remained substantially lower and was almost halved after adjustment for birth weight, extreme immaturity, lethal malformations, and confounding obstetric variables (P = 0.001). Fatal cases of respiratory distress syndrome were less common in the treated group (P = 0.044). Of in-hospital survivors, those in the treated group required less positive pressure respiratory support (P = 0.003) and fewer days in oxygen (P = 0.018), and the incidences of bronchopulmonary dysplasia (P = 0.003) and patent ductus arteriosus (P = 0.002) were lower. Two-year survivors who had received treatment were heavier (P = 0.016) and had larger head circumferences (P = 0.029). These beneficial associations in the treated group were not at the expense of increased rates of infection or adverse neurologic outcome. We did not detect any adverse effects of antenatal steroid therapy on any relevant aspect of mortality or morbidity in infancy under circumstances in which the chances of finding substantial differences were high.

Mortality and two year outcome of infants of birthweight 500-1500 g: relationship with neonatal cerebral ultrasound data

Cranial ultrasounds were performed on 218 (96%) of 227 liveborn infants of birthweight 500-1500 g delivered in the Royal Women's Hospital, Melbourne, Australia, in an 18-month period concluding in March 1982. Seventy-two (31.7%) of the children died; 28 children (38.9%) had cerebroventricular haemorrhage, 35 (48.6%) showed no bleeding and there were nine (12.5%) with no data. Paired necropsy and ultrasound data were congruent in 22 (88%) of 25 children. One hundred and forty-eight (95.5%) of 155 survivors were seen at 2 years of age. Forty-one (28%) had cerebroventricular haemorrhage; nine children (6%) had both ventricular dilatation and haemorrhage and two had ventricular dilatation alone. Apart from a marginal advance in gestation and higher number of immigrant and less educated mothers in children without cerebroventricular haemorrhage, all other perinatal, biographical and social variables between those with haemorrhage and those without were similar. The major handicap rate overall was 14.2% (21 patients). The children with cerebroventricular haemorrhage had a trend for greater prevalence of handicap and lower mean Bayley psychological scores. This was even more evident with ventricular dilatation being present. Of children with major handicap 57.1% (12/21) had normal serial ultrasound findings during their primary hospitalization. Major handicap occurred in 15% (3/20) of children with grade 1 haemorrhage, 23.5% (4/17) with grade 2 or 3 bleeds and 25% (1/4) of those with grade 4 haemorrhage. Laterality of cerebral palsy did not correlate with ultrasound findings. Ultrasound findings did not improve statistical prediction of deaths or major handicap.