Update of the Amiel-Tison neurologic assessment for the term neonate or at 40 weeks corrected age

Neurofunctional assessment at term equivalent age can predict 3-year neurodevelopmental outcomes in very low birth weight infants

AIM

Preterm infants are at high risk of developing motor delay, learning difficulties and behavioural problems and the availability of valid neurodevelopmental assessments is a major clinical issue. This study evaluated the relationship between preterm infants' neurofunctional assessment at term equivalent age and neurodevelopment outcome at three years of chronological age.

METHODS

Neurofunctional assessment was performed in 70 very low birth weight infants at term equivalent age and neurodevelopmental outcome was assessed at three years of chronological age with the Griffiths Mental Development Scale - Extended Revised.

RESULTS

At term equivalent age, 81% of the children had normal neurofunctional scores and 82.5% of those showed normal neurodevelopmental outcome at three years. Of the 19% who had impaired development at term equivalent age, 38.5% had neurodevelopmental delay at three years. Impaired neurofunctional status was associated with an increased risk of developmental delay in the global quotient (odds ratio 12.1) and locomotor sub-quotient (odds ratio 18.35) compared with normal neurofunctional status. Infants with sepsis or necrotising enterocolitis also faced a higher risk of neurodevelopmental delay.

CONCLUSION

Neurofunctional assessment performed at term equivalent age appeared to provide early identification of preterm infants at risk of neurodevelopmental delay at three years of chronological age.

Early functional and morphological brain disturbances in late-onset intrauterine growth restriction

AIMS

To determine whether the brain disturbances develop in late-onset intrauterine growth restriction (IUGR) before blood flow redistribution towards the fetal brain (detected by Doppler measurements in the middle cerebral artery and umbilical artery). Further, to evaluate predictive values of Doppler arterial indices and umbilical cord blood gases and pH for early functional and/or morphological brain disturbances in late-onset IUGR.

STUDY DESIGN

This cohort study included 60 singleton term pregnancies with placental insufficiency caused late-onset IUGR (IUGR occurring after 34 gestational weeks). Umbilical artery resistance index (URI), middle cerebral artery resistance index (CRI), and cerebroumbilical (C/U) ratio (CRI/URI) were monitored once weekly. Umbilical blood cord samples (arterial and venous) were collected for the analysis of pO2, pCO2 and pH. Morphological neurological outcome was evaluated by cranial ultrasound (cUS), whereas functional neurological outcome by Amiel-Tison Neurological Assessment at Term (ATNAT).

RESULTS

50 fetuses had C/U ratio>1, and 10 had C/U ratio≤1; among these 10 fetuses, 9 had abnormal neonatal cUS findings and all 10 had non-optimal ATNAT. However, the total number of abnormal neurological findings was much higher. 32 neonates had abnormal cUS (53.37%), and 42 (70.00%) had non-optimal ATNAT. Furthermore, Doppler indices had higher predictive validity for early brain disturbances than umbilical cord blood gases and pH. C/U ratio had the highest predictive validity with threshold for adverse neurological outcome at value 1.13 (ROC analysis), i.e., 1.18 (party machine learning algorithm).

CONCLUSION

Adverse neurological outcome at average values of C/U ratios>1 confirmed that early functional and/or structural brain disturbances in late-onset IUGR develop even before activation of fetal cardiovascular compensatory mechanisms, i.e., before Doppler signs of blood flow redistribution between the fetal brain and the placenta.

Moderate hypothermia within 6 h of birth plus inhaled xenon versus moderate hypothermia alone after birth asphyxia (TOBY-Xe): a proof-of-concept, open-label, randomised controlled trial

Background

Moderate cooling after birth asphyxia is associated with substantial reductions in death and disability, but additional therapies might provide further benefit. We assessed whether the addition of xenon gas, a promising novel therapy, after the initiation of hypothermia for birth asphyxia would result in further improvement.

Methods

Total Body hypothermia plus Xenon (TOBY-Xe) was a proof-of-concept, randomised, open-label, parallel-group trial done at four intensive-care neonatal units in the UK. Eligible infants were 36–43 weeks of gestational age, had signs of moderate to severe encephalopathy and moderately or severely abnormal background activity for at least 30 min or seizures as shown by amplitude-integrated EEG (aEEG), and had one of the following: Apgar score of 5 or less 10 min after birth, continued need for resuscitation 10 min after birth, or acidosis within 1 h of birth. Participants were allocated in a 1:1 ratio by use of a secure web-based computer-generated randomisation sequence within 12 h of birth to cooling to a rectal temperature of 33·5°C for 72 h (standard treatment) or to cooling in combination with 30% inhaled xenon for 24 h started immediately after randomisation. The primary outcomes were reduction in lactate to N-acetyl aspartate ratio in the thalamus and in preserved fractional anisotropy in the posterior limb of the internal capsule, measured with magnetic resonance spectroscopy and MRI, respectively, within 15 days of birth. The investigator assessing these outcomes was masked to allocation. Analysis was by intention to treat. This trial is registered with ClinicalTrials.gov, number NCT00934700, and with ISRCTN, as ISRCTN08886155.

Findings

The study was done from Jan 31, 2012, to Sept 30, 2014. We enrolled 92 infants, 46 of whom were randomly assigned to cooling only and 46 to xenon plus cooling. 37 infants in the cooling only group and 41 in the cooling plus xenon group underwent magnetic resonance assessments and were included in the analysis of the primary outcomes. We noted no significant differences in lactate to N-acetyl aspartate ratio in the thalamus (geometric mean ratio 1·09, 95% CI 0·90 to 1·32) or fractional anisotropy (mean difference −0·01, 95% CI −0·03 to 0·02) in the posterior limb of the internal capsule between the two groups. Nine infants died in the cooling group and 11 in the xenon group. Two adverse events were reported in the xenon group: subcutaneous fat necrosis and transient desaturation during the MRI. No serious adverse events were recorded.

Interpretation

Administration of xenon within the delayed timeframe used in this trial is feasible and apparently safe, but is unlikely to enhance the neuroprotective effect of cooling after birth asphyxia.

Funding

UK Medical Research Council.

Salivary lactate dehydrogenase levels can provide early diagnosis of hypoxic-ischaemic encephalopathy in neonates with birth asphyxia

AIM

Timely detection of hypoxic-ischaemic encephalopathy (HIE) is crucial for selecting neonates who are likely to benefit from neuroprotective therapy. This study evaluated the efficacy of salivary lactate dehydrogenase (LDH) in the early diagnosis of HIE among neonates with perinatal asphyxia.

METHODS

We prospectively enrolled 30 neonates who needed resuscitation at birth or had a history of delayed cry into the HIE group if they developed HIE within 12 h of birth. The control group comprised 30 neonates who had no evidence of HIE, but had intrapartum foetal distress or needed resuscitation at birth. LDH was measured using saliva samples collected within 12 h of birth.

RESULTS

Salivary LDH was significantly higher in the HIE group, with a median of 2578 and an interquartile range (IQR) of 1379-3408 international units per litre (IU/L), than in the control group (median 558.5, IQR: 348-924 IU/L, p < 0.001). The test demonstrated excellent discriminating ability: the area under the curve was 0.92 and the levels of 893 IU/L showed a sensitivity of 90% and a specificity of 73.3%.

CONCLUSION

Measuring salivary LDH among neonates with birth asphyxia provided an early and accurate diagnosis of HIE and could be used as a triage tool.

Neurodevelopmental outcome of high risk newborns discharged from special care baby units in a rural district in India

BACKGROUND

High risk newborns are most vulnerable to develop neuro-developmental delay (NDD). Early detection of delay in this group and identification of associated perinatal factors and their prevention can prevent disability in later life.

DESIGN AND METHODS

Observational cohort study. Field based tracking and neuro-developmental screening of high risk newborns discharged between January 2010 to June 2012 from a district Hospital in India was conducted by a team of developmental specialists, using standardized tools like Denver Developmental Screening Tool II, Trivandrum Developmental Screening Chart and Amiel-Tison method of tone assessment. Associated perinatal factors were identified. Early intervention was initiated on those detected with NDD.

RESULTS

Developmental delay was detected in 31.6% of study population. Prevalence of NDD was significantly higher in low birth weight (LBW, >2 kg), preterm (<36 weeks) and twins. Neonatal sepsis/meningitis and convulsions also showed significant association with NDD. Of the 134 with developmental delay, 61 were preterm, 80 LBW, with h/o sepsis in 52, convulsion in 14, birth asphyxia in 39 and jaundice in 14 neonates.

CONCLUSIONS

Incidence of NDD among high risk newborns is significantly high with LBW, prematurity and neonatal illnesses are major contributors. Most NDDs go undetected in the early years of life. Improved perinatal care, early detection and early intervention at the grass root level will bring down incidence of developmental challenges in this vulnerable group. Significance for public healthThe public health significance of this study lies in the fact that a large proportion of high-risk newborns in rural India were detected with developmental delay and some preventable perinatal and neonatal factors like prematurity, low birth weight, sepsis and meningitis were found to be associated with the problem. So, it suggests that prevention of these perinatal factors, timely detection with proper screening methods and early intervention will help curb the burden of disability in the community. Once a disability develops in a child, the magnitude of the problem swells in all aspects: medical, social and economic. But much of this burden can be lessened if we intervene early, as a third of most disabilities are preventable. Moreover, if we can identify the perinatal factors leading to neonatal brain damage and prevent them, much of the neuro-developmental delay can be averted.

Use of wind-up fetal Doppler versus Pinard for fetal heart rate intermittent monitoring in labour: a randomised clinical trial

OBJECTIVES

In resource-poor settings, the standard of care to inform labour management is the partograph plus Pinard stethoscope for intermittent fetal heart rate (FHR) monitoring. We compared FHR monitoring in labour using a novel, robust wind-up handheld Doppler with the Pinard as a primary screening tool for abnormal FHR on perinatal outcomes.

DESIGN

Prospective equally randomised clinical trial.

SETTING

The labour and delivery unit of a teaching hospital in Kampala, Uganda.

PARTICIPANTS

Of the 2042 eligible antenatal women, 1971 women in active term labour, following uncomplicated pregnancies, were randomised to either the standard of care or not.

INTERVENTION

Intermittent FHR monitoring using Doppler.

PRIMARY OUTCOME MEASURES

Incidence of FHR abnormality detection, intrapartum stillbirth and neonatal mortality prior to discharge.

RESULTS

Age, parity, gestational age, mode of delivery and newborn weight were similar between study groups. In the Doppler group, there was a significantly higher rate of FHR abnormalities detected (incidence rate ratio (IRR)=1.61, 95% CI 1.13 to 2.30). However, in this group, there were also higher though not statistically significant rates of intrapartum stillbirths (IRR=3.94, 0.44 to 35.24) and neonatal deaths (IRR=1.38, 0.44 to 4.34).

CONCLUSIONS

Routine monitoring with a handheld Doppler increased the identification of FHR abnormalities in labour; however, our trial did not find evidence that this leads to a decrease in the incidence of intrapartum stillbirth or neonatal death.

TRIAL REGISTRATION NUMBER

Clinical Trails.gov (1000031587).

Antenatal and Postnatal Assessment of Neurobehavior: Which One should be used?

It is obvious that this environment is quite different from one man is experiencing after birth, but, although different, intrauterine environment is ideal at that stage of human development. There is a question of the environmental discontinuity between intrauterine conditions characterized by existence of microgravity (baby astronaut hypothesis), and extrauterine life with gravity as developmental condition sine qua non. The human brain is one of the organs which is very sensitive to environmental changes affecting its growth and development. The brain of very tiny prematurely born babies is unable to follow the genetically determined growth pattern in extrauterine environment, even when postnatal nutrition and nurturing of the babies according to our best knowledge are appropriate. Is this fact of any significance to make distinction between normal and abnormal neurodevelopment pre- and postnatally is still unclear?

Kurjak antenatal neurodevelopmental test (KANET) using four-dimensional ultrasound (4D US) has been introduced using ten parameters and after attempt of standardization only eight parameters remained for neurodevelopmental assessment of low- and high-risk fetuses. We believe that at present level of knowledge, KANET test could be considered as a good test for the detection of fetuses with high neurological risk, without the possibility to define reliable long-term neurodevelopmental outcome. This is also hardly possible based on postnatal neurological assessment with 27 different postnatal tests. They were primarily neurobehavioral or neuromotor assessments that were suitable for use with preterm infants, and were discriminative, predictive or evaluative.

There was a high willingness of clinician to find postnatal neurodevelopmental test which could be predictive for short- term and long-term outcome of low and high-risk infants.

Although, there are many tests available for prenatal and postnatal assessment of neurodevelopment, none of them is reliable in the prediction of neurodevelopmental outcome in low-risk population, while many could be used with fairly acceptable predictivity in high-risk population. Although, many studies have been conducted in order to solve this problem, still there is a space for improvement. In postnatal period we are dealing with infant in front of the clinician with direct observation, while pretnatally we are dealing with quite different environment and less mature brain.

How to cite this article

Stanojevic M. Antenatal and Postnatal Assessment of Neurobehavior: Which One should be used? Donald School J Ultrasound Obstet Gynecol 2015;9(1):67-74.

KANET in Brazil: First Experience

Objective

The goal of this pilot test is to compare Kurjak's antenatal neurological test (KANET) results between high and low-risk pregnancies and see the feasibility of using this test on a larger scale in Brazil.

Methods

We applied KANET test in high-risk (n = 17) and low-risk (n = 34) pregnancies and compared the results.

Results

There was a significant difference between groups of high-risk and low-risk pregnancies for all parameters in KANET score 2. For KANET score 0, 5 out of 8 parameters where significant different: isolated head anteflexion, cranial sutures and head circumference, isolated hand movement or hand to face movements, isolated leg movement and fingers movements. All abnormal KANET result came from high-risk pregnancies (17.6%). No low-risk pregnancies presented KANET score 0. Efficacy and effectiveness were not evaluated due to the imprecision inherent in data from small samples.

Conclusion

This successful preliminary study of KANET in Brazil showed important differences in fetal behavior between the low and high-risk pregnancies, and can be used as information of feasibility and identify modifications needed in the design of a larger testing study.

How to cite this article

Neto RM. KANET in Brazil: First Experience. Donald School J Ultrasound Obstet Gynecol 2015;9(1):1-5.

First Experience in Clinical Application of KANET

Introduction of three- and four-dimensional ultrasound into clinical practice enabled qualitative and quantitative assessment of fetal movements, including the analysis of fetal face expression which is considered to be the mirror of the maturational processes of upper motor neuron. Since, prenatal fetal behavioral patterns are reflections of developmental and maturational processes within the fetal central nervous system, the findings about changes in fetal movements and behavior could leed to the prenatal diagnosis of neurological impairment. Kurjak's antenatal neurodevelopment test (KANET) is the first prenatal test based on the three- and four-dimensional ultrasound examination of the fetus that could be used for the evaluation and prediction of the fetal neurologic status.

How to cite this article

Luetic AT. First Experience in Clinical Application of KANET. Donald School J Ultrasound Obstet Gynecol 2015;9(1):96-99.

Fetal Neurology: Past, Present and Future

Neurological failure is the most apprehension complication of pregnancy, labor and the neonatal period. The origin and outcome correlation is frequently doubtful. The arrival of four-dimensional ultrasonography (4D US) and its function to study fetal behavior patterns have initiated to offer insight into the structural and functional fetal brain development. Although many fetal behavioral studies have been conducted, it is still questionable whether the assessment of continuity from fetal to neonatal behavior could improve our ability of early detection of brain pathology. Neurological assessment of fetus in utero is extremely difficult even having such sophisticated equipment like 4D ultrasound. As it is well known that quantity of GMs is not so informative and predictive for neurological impairment, their quality should be assessed. Gestalt perception of premature GMs we are dealing with in utero and several weeks postnatally are not as predictive for the detection of neurologically abnormal fetuses or newborns as fidgety GMs. Therefore, some additional parameters should be added to the prenatal neurological examination in order to improve our ability to make the distinction between normal and abnormal fetuses.

How to cite this article

Kurjak A, Antsaklis P, Stanojevic M. Fetal Neurology: Past, Present and Future. Donald School J Ultrasound Obstet Gynecol 2015;9(1):6-29.

Is in utero Fetal Neurological Assessment Comparable to Postnatal Neurological Assessment?

The traditional concept that brain damage is caused during birth or early neonatal period has been challenged. This is supported by the fact that the incidence of cerebral palsy stayed unchanged despite the global increase of cesarean sections. Consequently, the medicolegal importance of fetal neurological research is essential and needed. Years of research have provided us with important knowledge about association of fetal movements with brain development. The basic studies were done by two-dimensional ultrasound. The implementation of four-dimensional ultrasound in evaluation of fetal behavior has opened new and unexplored possibilities of evaluating the quality of fetal movements and a detailed assessment of fetal facial expressions. It is known that early postnatal neurological assessment, regarding future prediction of neurological optimality, has great limitations do to wonderful brain plasticity. Taking this very important limitation in to the account we could conclude that the preliminary studies comparing prenatal and postnatal neurological assessment are comparable. More importantly they emphasize the fact that the study of fetal behavior is most probably the right path in the study of fetal neurological development.

How to cite this article

Vasilj O. Is in utero Fetal Neurological Assessment Comparable to Postnatal Neurological Assessment? Donald School J Ultrasound Obstet Gynecol 2015; 9(1):91-95.

[Early prediction of the neurological result at 12 months in newborns at neurological risk]

INTRODUCTION

The aim of this study was to evaluate the Amiel-Tison neurological examination (AT) and cranial ultrasound at term for predicting the neurological result at 12 months in newborns with neurological risk.

PATIENTS AND METHODS

The study included 89 newborns with high risk of neurological damage, who were discharged from the Neonatal Intensive Care of the Hospital Zonal Bariloche, Argentina. The assessment consisted of a neurological examination and cranial ultrasound at term, and neurological examination and evaluation of development at 12 months. The sensitivity, specificity, positive and negative predictor value was calculated. The relationship between perinatal factors and neurodevelopment at 12 month of age was also calculated using logistic regression models.

RESULTS

Seventy children completed the follow-up. At 12 months of age, 14% had an abnormal neurological examination, and 17% abnormal development. The neurological examination and the cranial ultrasound at term had low sensitivity to predict abnormal neurodevelopment. At 12 months, 93% of newborns with normal AT showed normal neurological results, and 86% normal development. Among newborns with normal cranial ultrasound the percentages were 90 and 81%, respectively. Among children with three or more perinatal risk factors, the frequency of abnormalities in the neurological response was 5.4 times higher than among those with fewer risk factors, and abnormal development was 3.5 times more frequent.

CONCLUSIONS

The neurological examination and cranial ultrasound at term had low sensitivity but high negative predictive value for the neurodevelopment at 12 months. Three or more perinatal risk factors were associated with neurodevelopment abnormalities at 12 months of age.

Relationship between neurological assessments of preterm infants in the first 2 years and cognitive outcome at school age

BACKGROUND

The risk of cognitive disability in preterm infants is higher than in general population. The Amiel-Tison neurological assessment could be a useful tool for early identification of preterm children at risk of cognitive disability in school age. This study investigated the value of categorization of neurological signs assessed by the Amiel-Tison neurological assessment in the first 2 years of life in relation to cognitive performance at school age in a group of preterm children.

METHODS

Preterm children with gestational age from 23 to 36 weeks were included in the prospective study. From the initial group of 45 children, in whom the Amiel-Tison neurological assessment was performed at term age, at 3 months corrected age, and at 2 years, the Wechsler Intelligence Scale for Children-third edition was performed in 39 children after school entry.

RESULTS

Full scale IQ, Verbal IQ, and Performance IQ of the whole group of preterm children were not significantly different from the normative data; most of the children had IQ scores in the normal range (≥85). The mean cognitive results of children decreased as the number of neurological signs increased. There was a significant correlation between the categories of neurological signs at 2 years and later cognitive results.

CONCLUSIONS

The grade of severity of neurological signs at 2 years was associated with the cognitive results at school age. The categorization of neurological signs according to the Amiel-Tison neurological assessment in preterm children might have prognostic value for cognitive outcome at school age.

Is startle a lateralised response in early infancy?

The aim of the study was to explore whether the acoustic startle response shows signs of early lateralisation. Using non-invasive startle measurements (Automated Infant Motor Movement Startle Seat and Facial Action Coding System), an analysis of response latencies and intensities on the right and left body sides was performed, investigating the presence of asymmetries on the whole-body startle and on the facial component of the startle motor pattern in a group of 5-month-old infants. The findings suggest that the infant whole-body startle is a lateralised response, characterised by a right bias latency. This lateralisation could reflect an underlying lateralised organisation of the infant startle neural circuitry. On the other hand, the analysis of the facial component of the startle motor pattern did not reveal any significant asymmetry. The discrepancy found in the whole-body response and in the startle facial component will be discussed, reflecting on the limits of the adopted methodologies. The use of a high-speed camcorder might allow future research to analyse more in depth the startle fast face responses.

The safe passage study: design, methods, recruitment, and follow-up approach

BACKGROUND

The Safe Passage Study is a large, prospective, multidisciplinary study designed to (1) investigate the association between prenatal alcohol exposure, sudden infant death syndrome (SIDS), and stillbirth, and (2) determine the biological basis of the spectrum of phenotypic outcomes from exposure, as modified by environmental and genetic factors that increase the risk of stillbirth, SIDS, and in surviving children, fetal alcohol spectrum disorders.

METHODS

The results provided are based on an interim assessment of 6004 women enrolled, out of the 12,000 projected, from the Northern Plains, US, and Cape Town, South Africa, areas known to be of high risk for maternal drinking during pregnancy. Research objectives, study design, and descriptive statistics, including consent, recruitment, and retention information, are provided.

RESULTS

Overall visit compliance is 87%, and includes prenatal, delivery/newborn, and postnatal contacts through 1 year post-delivery. Pregnancy outcome ascertainment is 98% prior to medical chart review; less than 2% of women withdraw. Consent for the use of DNA and placental tissue exceed 94%, and consent to participate in the autopsy portion of the study is 71%.

CONCLUSIONS

The Safe Passage Study is the first multi-site study of SIDS and stillbirth to integrate prospectively collected exposure information with multidisciplinary biological information in the same maternal and fetal/infant dyad using a common protocol. Essential components of the study design and its success are close ties to the community and rigorous systems and processes to ensure compliance with the study protocol and procedures.

Prenatal exposure to manganese at environment relevant level and neonatal neurobehavioral development

BACKGROUND

Effects of prenatal Manganese (Mn) exposure at an environmental relevant level on neonatal neurodevelopment remains unclear.

OBJECTIVES

In the multi-center study, we assessed the impact of low level prenatal Mn exposure on neonatal behavioral neurological assessments (NBNA), and explore a threshold umbilical cord blood Mn on neonatal neurological development.

METHODS

We investigated 933 mother-newborn pairs in Shanghai, China, from 2008 through 2009. Umbilical cord serum concentrations of Mn were measured and NBNA tests were conducted. The NBNA contains five clusters: behavior, active tone, passive tone, primary reflexes and general assessment with a maximal total score of 40. The score<37 is defined as low.

RESULTS

The median serum Mn concentration was 4.0 μg/L. Of the 933 infants, 44 (4.7%) had low NBNA. After adjusting for potential confounders, a high level of Mn (≥ 75th percentile ) was associated with a lower NBNA score (adjusted ß=-1.1, 95% CI: -1.4-0.7, p<0.01) and a higher risk of low NBNA (adjusted OR=9.4, 95% CI: 3.4-25.7, p<0.01). A nonlinear relationship was observed between cord serum Mn and NBNA after adjusting for potential confounders. NBNA score decreased with increasing Mn levels after 5.0 μg/L(LgMn ≥ 0.7). The cord serum Mn ≥ 5.0 μg/L had adverse effects on behavior, active tone and general reactions of clusters (p<0.001).

CONCLUSIONS

High prenatal Mn exposure even at an environmental relevant level, is associated with poor fetal neurobehavioral development in a nonlinear pattern. A threshold cord serum Mn of 5.0 μg/L existed for lower neonatal behavioral neurological assessments.

[Motor behavior of human fetuses during the second trimester of gestation: a longitudinal ultrasound study]

INTRODUCTION

The aim of this research is to contribute to knowledge of the normal spontaneous motor behavior of the human fetus during the second trimester of pregnancy. This study focuses on five patterns of spontaneous fetal movement: startle (S), axo-rhizomelic rhythmia (ARR), axial stretching (AS), general movement (GM), and diaphragmatic contraction (DC).

METHODS

A cohort of 13 subjects was followed up using 2D obstetrical ultrasound images at 12, 16, 20, and 24 weeks of gestation. As inclusion criteria, neonatal neurological examination and general movements after eutocic delivery at term were normal in all of the subjects, and their neuromotor and cognitive development until the end of pre-school age were also normal.

RESULTS

All these five motor patterns are present at the beginning of the 2(nd) gestational trimester, but their quantitative and qualitative traits are diverse according to gestational ages. The phasic, isolated or rhythmically repeated movements, S and ARR, are prominent at 12 and 16 weeks of gestation, and then their presence gradually diminishes. By contrast, tonic and complex AS and GM movements increase their presence and quality at 20 and 24 weeks. RAR constitute a particular periodic motor pattern not described in previous literature. Moreover, the incidence of DC is progressive throughout the trimester, in clusters of 2-6 arrhythmic and irregular beats. Fetal heart rate increases during fetal motor active periods.

CONCLUSIONS

All five normal behavioral patterns observed in the ultrasounds reflect the progressive tuning of motor generators in human nervous system during mid-pregnancy.

Sleep EEG composition in the first three months of life in monozygotic and dizygotic twins

We investigated genetic influence on sleep electroencephalogram (EEG) composition by a classical twin study of monozygotic (MZ) and dizygotic (DZ) twins in the first 3 months of life. Polysomnographic (PSG) recordings were obtained in 10 MZ and 20 DZ twin pairs in the 37th, 46th, and 52nd week of postmenstrual age (PMA). The EEG power spectra were generated on the basis of fast Fourier transformation (FFT). Genetic influence on active sleep/rapid eye movement (AS/REM)] and quiet sleep/non rapid eye movement (QS/NREM) sleep composition was estimated by calculating within pair concordance and the intraclass correlation coefficients (ICCs) for delta (0.5-3.5 Hz), theta (4-7.5 Hz), alpha (8-11.5 Hz), sigma (12-14 Hz), and beta (14.5-20 Hz) at central derivation. MZ twins show higher ICCs than DZ twins for alpha, sigma, and beta spectral powers during QS/NREM sleep in the 37th, 46th, and 52nd week PMA. However, there was no significant difference (P > .05) between the 2 types of twins in absolute differences of EEG spectral power of the alpha, beta, and sigma frequency ranges in the 37th, 46th, and 52nd week PMA. The greatest mean absolute difference within MZ and DZ twin pairs and also between MZ and DZ twin groups was identified in the delta frequency range. Our findings gave an indication of genetic influence on alpha, sigma, and beta frequency ranges in the QS/NREM sleep stage.

Therapeutic cooling for perinatal asphyxia-Indian experience

Therapeutic hypothermia (TH) has been established as standard of care for term babies with perinatal asphyxia in developed countries. However, it is yet to gain momentum in India. This review summarizes some of the TH trials conducted in India and the various related issues in adapting the same for the Indian context.

Adherence to hypothermia guidelines: a French multicenter study of fullterm neonates

AIM

The objective of this study was to describe the French practice of hypothermia treatment (HT) in full-term newborns with hypoxic-ischemic encephalopathy (HIE) and to analyze the deviations from the guidelines of the French Society of Neonatology.

MATERIALS AND METHODS

From May 2010 to March 2012 we recorded all cases of HIE treated by HT in a French national database. The population was divided into three groups, "optimal HT" (OHT), "late HT" (LHT) and "non-indicated" HT (NIHT), according to the guidelines.

RESULTS

Of the 311 newborns registered in the database and having HT, 65% were classified in the OHT group, 22% and 13% in the LHT and NIHT groups respectively. The severity of asphyxia and HIE were comparable between newborns with OHT and LHT, apart from EEG. HT was initiated at a mean time of 12 hours of life in the LHT group. An acute obstetrical event was more likely to be identified among newborns with LHT (46%), compared to OHT (34%) and NIHT (22%). There was a gradation in the rate of complications from the NIHT group (29%) to the LHT (38%) group and the OHT group (52%). Despite an insignificant difference in the rates of death or abnormal neurological examination at discharge, nearly 60% of newborns in the OHT group had an MRI showing abnormalities, compared to 44% and 49% in the LHT and NIHT groups respectively.

CONCLUSION

The conduct of the HT for HIE newborns is not consistent with French guidelines for 35% of newborns, 22% being explained by an excessive delay in the start of HT, 13% by the lack of adherence to the clinical indications. This first report illustrates the difficulties in implementing guidelines for HT and should argue for an optimization of perinatal care for HIE.

Video-EEG recordings in full-term neonates of diabetic mothers: observational study

OBJECTIVE

To determine whether full-term newborn infants of diabetic mothers (IDM) present immature/disorganised EEG patterns in the immediate neonatal period, and whether there was any relationship with maternal glycaemic control.

DESIGN AND SETTING

Cohort study with an incidental sample performed in a tertiary hospital neonatal unit.

PATIENTS

23 IDM and 22 healthy newborns born between 2010 and 2013.

INTERVENTIONS

All underwent video-EEG recording lasting >90 min at 48-72 h of life.

MAIN OUTCOME MEASURES

We analysed the percentage of indeterminate sleep, transient sharp waves per hour and mature-for-gestational age EEG patterns (discontinuity, maximum duration of interburst interval (IBI), asynchrony, asymmetry, δ brushes, encoches frontales and α/θ rolandic activity). The group of IDM was divided into two subgroups according to maternal HbA1c: (1) HbA1c≥6% and (2) HbA1c<6%.

RESULTS

Compared with healthy newborns, IDM presented significantly higher percentage of indeterminate sleep (57% vs 25%; p<0.001), discontinuity (2.5% vs 0%; p=0.044) and δ brushes in the bursts (6% vs 3%; p=0.024); higher duration of IBI (0.3 s vs 0 s; p=0.017); fewer encoches frontales (7/h vs 35/h; p<0.001), reduced θ/α rolandic activity (3/h vs 9/h; p<0.001); and more transient sharp waves (25/h vs 5/h; p<0.001). IDM with maternal HbA1c≥6% showed greater percentage of δ brushes in the burst (14% vs 4%; p=0.007).

CONCLUSIONS

Full-term IDM newborns showed video-EEG features of abnormal development of brain function. Maternal HbA1c levels<6% during pregnancy could minimise the risk of cerebral dysmaturity.

Neonatal neurobehavioral abnormalities and MRI brain injury in encephalopathic newborns treated with hypothermia

BACKGROUND

Neonatal Encephalopathy (NE) is a prominent cause of infant mortality and neurodevelopmental disability. Hypothermia is an effective neuroprotective therapy for newborns with encephalopathy. Post-hypothermia functional-anatomical correlation between neonatal neurobehavioral abnormalities and brain injury findings on MRI in encephalopathic newborns has not been previously described.

AIM

To evaluate the relationship between neonatal neurobehavioral abnormalities and brain injury on magnetic resonance imaging (MRI) in encephalopathic newborns treated with therapeutic hypothermia.

STUDY DESIGN

Neonates with hypoxic ischemic encephalopathy (HIE) referred for therapeutic hypothermia were prospectively enrolled in this observational study. Neurobehavioral functioning was assessed with the NICU network neurobehavioral scale (NNNS) performed at target age 14 days. Brain injury was assessed by MRI at target age 7-10 days. NNNS scores were compared between infants with and without severe MRI injury.

SUBJECTS & OUTCOME MEASURES

Sixty-eight term newborns (62% males) with moderate to severe encephalopathy underwent MRI at median 8 days (range 5-16) and NNNS at median 12 days of life (range 5-20). Fifteen (22%) had severe injury on MRI.

RESULTS

Overall Total Motor Abnormality Score and individual summary scores for Non-optimal Reflexes and Asymmetry were higher, while Total NNNS Z-score across cognitive/behavioral domains was lower (reflecting poorer performance) in infants with severe MRI injury compared to those without (p < 0.05).

CONCLUSIONS

Neonatal neurobehavioral abnormalities identified by the NNNS are associated with MRI brain injury in encephalopathic newborns post-hypothermia. The NNNS can provide an early functional assessment of structural brain injury in newborns, which may guide rehabilitative therapies in infants after perinatal brain injury.

1H NMR derived metabolomic profile of neonatal asphyxia in umbilical cord serum: implications for hypoxic ischemic encephalopathy

Neonatal hypoxic ischemic encephalopathy (HIE) is a severe consequence of perinatal asphyxia (PA) that can result in life-long neurological disability. Disease mechanisms, including the role and interaction of individual metabolic pathways, remain unclear. As hypoxia is an acute condition, aerobic energy metabolism is central to global metabolic pathways, and these metabolites are detectable using 1H NMR spectroscopy, we hypothesized that characterizing the NMR-derived umbilical cord serum metabolome would offer insight into the consequences of PA that lead to HIE. Fifty-nine at-risk infants were enrolled, together with 1:1 matched healthy controls, and stratified by disease severity (n=25, HIE; n=34, non-HIE PA). Eighteen of 37 reproducibly detectable metabolites were significantly altered between study groups. Acetone, 3-hydroxybutyrate, succinate, and glycerol were significantly differentially altered in severe HIE. Multivariate data analysis revealed a metabolite profile associated with both asphyxia and HIE. Multiple-linear regression modeling using 4 metabolites (3-hydroxybutyrate, glycerol, O-phosphocholine, and succinate) predicted HIE severity with an adjusted R2 of 0.4. Altered ketones suggest that systemic metabolism may play a critical role in preventing neurological injury, while altered succinate provides a possible explanation for hypoxia-inducible factor 1-α (HIF-1α) stabilization in HI injury.

Postasphyxial renal injury in newborns as a prognostic factor of neurological outcome

OBJECTIVE

To estimate if an acute postasphyxial renal injury in newborns could indicate a neurological outcome.

METHODS

We conducted a prospective clinical trial on 50 full-term newborns with 5-minute Apgar score <7 (asphyxiated group) and a control group of 50 full-term newborns with 5-min Apgar score ≥ 7 (non-asphyxiated group). Renal function was assessed on the third day of life by serum values of creatinine, cystatin C and β2-microglobulin (β2M) and glomerular filtration rate (GFR). All newborns had brain and renal ultrasonography at early stages and were followed by Amiel-Tison Neurological Assassment (ATNA) throughout the first year of life.

RESULTS

Mean GFR was significantly lower in asphyxiated than in non-asphyxiated group (22.08 ± 6.66 ml/min/1, 73 m(2) versus 35.42 ± 2.26 ml/min/1, 73 m(2); p < 0.001) and serum values of creatinine, cystatin C and β2M were significantly higher (1.13 versus 0.66 mg/dl; 3.92 versus 1.52 mg/l; 1.53 versus 0.99 mg/l; p < 0.001). In asphyxiated group ATNA results throughout the first year of life significantly correlated with renal function (p < 0.01). A correlation of ATNA with Apgar score at 5 min, Sarnat and Sarnat staging of hypoxic ischemic encephalopathy and brain and renal ultrasonography has also been significant (p < 0.01).

CONCLUSIONS

Our study showed a significant correlation between early impairment of renal function due to neonatal asphyxia with neurological outcome at the end of the first year of life.

Different levels of prenatal zinc and selenium had different effects on neonatal neurobehavioral development

Either deficient or excessive of essential nutrients had adverse effects. Effects of different levels of prenatal zinc (Zn) and selenium (Se) on fetal neurobehavioral development remain unclear. To determine the effects of different cord serum levels of Zn and Se on neurobehavioral development in neonates and to explore possible threshold level of Zn and Se based on fetal neurodevelopment, we conducted this epidemiological research. In the multi-center study, we investigated these questions in 927 mother-newborn pairs in Shanghai, China, from 2008 through 2009. Umbilical cord serum concentrations of Zn and Se were measured and Neonatal Behavioral Neurological Assessment (NBNA) tests were conducted. The median cord serum Zn and Se concentrations were 794.3 μg/L and 63.1 μg/L, respectively. A nonlinear relationship was observed between cord serum Zn and NBNA after adjusting for potential confounders. NBNA score decreased with increasing Zn levels after 794.3 μg/L (adjusted β=-3.0, 95% CI: -3.6 to -2.4, p<0.001). Additionally, an invert U-shape with a threshold Se of 100 μg/L was observed between cord serum Se and NBNA. The adjusted regression coefficient was 4.4 (95% CI: 3.6-5.2, p<0.001) for Se<100 μg/L while -3.6 (95% CI: -6.1 to -1.1, p<0.01) for Se≥100 μg/L. Of the 927 infants, 50% had a high level Zn (≥794.3 μg/L) and 8.6% had a high level Se (≥100 μg/L). High levels of both Zn and Se mainly had adverse effects on behavior and passive tone (p<0.001). Taken together, our study suggested that a threshold of cord blood Zn and Se was existed for fetal neurodevelopment and the prevalence of excessive Zn was high. Thus, the supplementation of Zn during pregnancy should be considered with caution in Shanghai, China.

Spontaneous movements in the supine position of healthy term infants and preterm infants with or without periventricular leukomalacia

AIM

The individual motor elements presumed to be essential for motor development were determined from spontaneous movements involving the entire body of normal term and preterm infants. Then, diagnostic items for motor abnormality in infants with periventricular leukomalacia (PVL) were investigated.

METHODS

Video recordings of 24 healthy term infants, 21 normal preterm infants (8 males, 13 females; median gestational age 30 weeks; median birth weight 1216g) and 14 preterm infants with PVL (6 males, 8 females; median gestational age 30 weeks; median birth weight 1360g) were analyzed.

RESULTS

In healthy term infants, predominant shoulder rotation was noticed until 1 month of age. After 2 months of age, isolated movements of the shoulder, elbow, hip, knee, and ankle frequently emerged. In preterm infants with PVL at the corrected age of 2 months, startle response and predominant shoulder rotation were more frequently seen and isolated neck, shoulder, elbow, hip, knee, and ankle movements were less frequently seen than in the normal preterm infants (Fisher's exact test, p<0.025).

INTERPRETATION

At 2 months of age, isolated movements evolve, and their failure to occur is suggested to be a useful sign for the diagnosis of cerebral motor disorders.

Therapeutic hypothermia in term infants after perinatal encephalopathy: the last 5 years in Switzerland

BACKGROUND

Therapeutic hypothermia (TH) following perinatal asphyxial encephalopathy in term infants improves mortality and neurodevelopmental outcome. In Europe, most neonatal units perform active cooling whereas in Switzerland passive cooling is predominantly used.

AIMS

(i) To determine how many infants were cooled within the last 5years in Switzerland, (ii) to assess the cooling methods, (iii) to evaluate the variation of temperature of different cooling methods, and (iv) to evaluate the use of neuromonitoring.

STUDY DESIGN

Retrospective cohort study.

PATIENTS

Notes of all cooled term infants between March 2005 and December 2010 in 9 perinatal and two paediatric intensive care centres were retrospectively reviewed. Active cooling was compared to passive cooling alone and to passive cooling in combination with gel packs.

RESULTS

150 infants were cooled. Twenty-seven (18.2%) were cooled actively, 34 (23%) passively and 87 (58.8%) passively in combination with gel packs. Variation of temperature was significantly different between the three methods. Passive cooling had a significant higher variation of temperature (SD of 0.89) than both passive cooling in combination with gel packs (SD of 0.79) and active cooling (SD of 0.76). aEEG before TH was obtained in 35.8% of the infants and 86.5% had full EEG. One cUS was performed in 95.3% and MRI in 62.2% of the infants.

CONCLUSION

Target temperature can be achieved with all three cooling methods. Passive cooling has the highest variation of temperature. Neuromonitoring should be improved in Swiss neonatal and paediatric intensive care units. Our results stress the importance of national registries.

Neurological assessment of preterm infants for predicting neuromotor status at 2 years: results from the LIFT cohort

OBJECTIVE

To develop a predictive risk stratification model for the identification of preterm infants at risk of 2-year suboptimal neuromotor status.

DESIGN

Population-based observational study.

SETTING

Regional preterm infant follow-up programme (Loire Infant Follow-up Team (LIFT) cohort) implemented in 2003.

PARTICIPANTS

4030 preterm infants were enrolled in the LIFT cohort, and examined by neonatologists using a modified version of the Amiel-Tison neurological assessment tool.

MAIN OUTCOME CRITERIA

2 year neuromotor status based on clinical examinations was conducted by trained paediatricians and parents' responses to the Ages and Stages Questionnaire were reported.

RESULTS

At 2 years of corrected age, 3321 preterm infants were examined, and suboptimal neuromotor status was found in 355 (10.7%). The study population was divided into training and validation sets. In the training set, 13 neonatal neurological items were associated with a 2-year suboptimal neuromotor status. Having at least one abnormal item was defined as an abnormal neurological status at term. In the validation set, these data predicted a 2-year suboptimal neuromotor status with a sensitivity of 0.55 (95% CI 0.47 to 0.62) and a specificity of 0.65 (95% CI 0.62 to 0.67). Two predictive risk stratification trees were built using the training set, which were based on the neurological assessment at term along with either gestational age or severe cranial lesions or birth weight. Using the validation set, the first tree identified a subgroup with a relatively low risk of suboptimal neuromotor status (3%), representing 32% of infants, and the second tree identified a subgroup with a risk of 5%, representing 42% of infants.

CONCLUSION

A normal neurological assessment at term allows the identification of a subgroup of preterm infants with a lower risk of non-optimal neuromotor development at 2 years.

The metabolomic profile of umbilical cord blood in neonatal hypoxic ischaemic encephalopathy

Background

Hypoxic ischaemic encephalopathy (HIE) in newborns can cause significant long-term neurological disability. The insult is a complex injury characterised by energy failure and disruption of cellular homeostasis, leading to mitochondrial damage. The importance of individual metabolic pathways, and their interaction in the disease process is not fully understood. The aim of this study was to describe and quantify the metabolomic profile of umbilical cord blood samples in a carefully defined population of full-term infants with HIE.

Methods and Findings

The injury severity was defined using both the modified Sarnat score and continuous multichannel electroencephalogram. Using these classification systems, our population was divided into those with confirmed HIE (n = 31), asphyxiated infants without encephalopathy (n = 40) and matched controls (n = 71). All had umbilical cord blood drawn and biobanked at −80°C within 3 hours of delivery. A combined direct injection and LC-MS/MS assay (AbsolutIDQ p180 kit, Biocrates Life Sciences AG, Innsbruck, Austria) was used for the metabolomic analyses of the samples. Targeted metabolomic analysis showed a significant alteration between study groups in 29 metabolites from 3 distinct classes (Amino Acids, Acylcarnitines, and Glycerophospholipids). 9 of these metabolites were only significantly altered between neonates with Hypoxic ischaemic encephalopathy and matched controls, while 14 were significantly altered in both study groups. Multivariate Discriminant Analysis models developed showed clear multifactorial metabolite associations with both asphyxia and HIE. A logistic regression model using 5 metabolites clearly delineates severity of asphyxia and classifies HIE infants with AUC = 0.92. These data describe wide-spread disruption to not only energy pathways, but also nitrogen and lipid metabolism in both asphyxia and HIE.

Conclusion

This study shows that a multi-platform targeted approach to metabolomic analyses using accurately phenotyped and meticulously biobanked samples provides insight into the pathogenesis of perinatal asphyxia. It highlights the potential for metabolomic technology to develop a diagnostic test for HIE.

Neurodevelopmental outcome of preterm very low birth weight infants born from 2005 to 2007

OBJECTIVE

To evaluate short-term neurodevelopmental outcome (at 24 months of corrected age) and correlations with obstetric and neonatal factors in a sample of preterm very low birth weight infants born and admitted to an Italian tertiary centre between 2005 and 2007.

METHODS

156 infants with a birth weight ≤ 1500 g (gestational age, range: 27-31 weeks) were followed at regular intervals through neurodevelopmental (neurological and psychomotor) assessment up to 24 months of corrected age. A statistical analysis was conducted in order to look for correlations between pre- and perinatal variables and neuropsychomotor outcome at 24 months.

RESULTS

131 children were classified as normal and the other 25 presented sequelae classified as "minor" in 17 cases and as "major" in eight. The most significant risk factors for a poor outcome were preterm premature rupture of the membranes, bronchodysplasia, late-onset sepsis, postnatal steroid therapy and male gender. The presence of severe abnormalities on brain ultrasound scan and of an abnormal neurological assessment at 40 weeks at term equivalent age were strong predictors of poor outcome.

CONCLUSIONS

Our study is one of the few investigating the short-term outcome of preterm VLBW Italian children born in the second half of the 2000s. Neurodevelopmental assessment at 24 months revealed a marked reduction in major sequelae. Several risk factors for a poor neurodevelopmental outcome identified in children born in earlier periods were confirmed in these children born in recent years.

Epileptic encephalopathy in children with risk factors for brain damage

In the study of 887 new born infants with prenatal and perinatal risk factors for brain damage, 11 children with West syndrome that progressed into Lennox-Gastaut syndrome and another 4 children with Lennox-Gastaut syndrome that had not been preceded by West syndrome were found. In this study we present the main findings of these 15 subjects. In all infants multifactor antecedents were detected. The most frequent risk factors were prematurity and severe asphyxia; however placenta disorders, sepsis, and hyperbilirubinemia were also frequent. In all infants MRI direct or secondary features of periventricular leukomalacia were observed. Followup of all infants showed moderate to severe neurodevelopmental delay as well as cerebral palsy. It is concluded that prenatal and perinatal risk factors for brain damage are very important antecedents that should be taken into account to follow up those infants from an early age in order to detect and treat as early as possible an epileptic encephalopathy.

Biomarkers of brain injury in neonatal encephalopathy treated with hypothermia

OBJECTIVE

To determine if early serum S100B and neuron-specific enolase (NSE) levels are associated with neuroradiographic and clinical evidence of brain injury in newborns with encephalopathy.

STUDY DESIGN

Patients who received therapeutic whole-body hypothermia were prospectively enrolled in this observational study. Serum specimens were collected at 0, 12, 24, and 72 hours of cooling. S100B and NSE levels were measured by enzyme linked immunosorbent assay. Magnetic resonance imaging was performed in surviving infants at 7-10 days of life. Standardized neurologic examination was performed by a child neurologist at 14 days of life. Multiple linear regression analyses were performed to evaluate the association between S100B and NSE levels and unfavorable outcome (death or severe magnetic resonance imaging injury/significant neurologic deficit). Cutoff values were determined by receiver operating curve analysis.

RESULTS

Newborns with moderate to severe encephalopathy were enrolled (n = 75). Median pH at presentation was 6.9 (range, 6.5-7.35), and median Apgar scores of 1 at 1 minute, 3 at 5 minutes, and 5 at 10 minutes. NSE and S100B levels were higher in patients with unfavorable outcomes across all time points. These results remained statistically significant after controlling for covariables, including encephalopathy grade at presentation, Apgar score at 5 minutes of life, initial pH, and clinical seizures.

CONCLUSION

Elevated serum S100B and NSE levels measured during hypothermia were associated with neuroradiographic and clinical evidence of brain injury in encephalopathic newborns. These brain-specific proteins may be useful immediate biomarkers of cerebral injury severity.

Visual performance in preterm infants with brain injuries compared with low-risk preterm infants

BACKGROUND

Neonatal brain injuries are the main cause of visual deficit produced by damage to posterior visual pathways. While there are several studies of visual function in low-risk preterm infants or older children with brain injuries, research in children of early age is lacking.

AIM

To assess several aspects of visual function in preterm infants with brain injuries and to compare them with another group of low-risk preterm infants of the same age.

STUDY DESIGN AND SUBJECTS

Forty-eight preterm infants with brain injuries and 56 low-risk preterm infants.

OUTCOME MEASURES

The ML Leonhardt Battery of Optotypes was used to assess visual functions. This test was previously validated at a post-menstrual age of 40 weeks in newborns and at 30-plus weeks in preterm infants.

RESULTS

The group of preterm infants with brain lesions showed a delayed pattern of visual functions in alertness, fixation, visual attention and tracking behavior compared to infants in the healthy preterm group. The differences between both groups, in the visual behaviors analyzed were around 30%. These visual functions could be identified from the first weeks of life.

CONCLUSION

Our results confirm the importance of using a straightforward screening test with preterm infants in order to assess altered visual function, especially in infants with brain injuries. The findings also highlight the need to provide visual stimulation very early on in life.

Neonatal factors associated with alteration of palatal morphology in very preterm children: the EPIPAGE cohort study

BACKGROUND

Altered palatal morphology has been observed among some preterm children, with possible consequences on chewing, speaking and esthetics, but determinants remain unknown.

AIM

To explore the role of neonatal characteristics and neuromotor dysfunction in alteration of palatal morphology at 5 years of age in very preterm children.

STUDY DESIGN

Prospective population-based cohort study.

SUBJECTS

1711 children born between 22 and 32 weeks of gestation in 1997 or born between 22 and 26 weeks of gestation in 1998 were included in the study. They all had a medical examination at 5 years of age.

OUTCOME MEASURES

Alteration of palatal morphology.

RESULTS

The prevalence of altered palatal morphology was 3.7% in the overall sample, 5.1% among boys and 2.2% among girls (adj OR: 2.52; 95%CI: 1.44-4.42). The risk for altered palatal morphology was higher for lower gestational age (adj OR: 0.85; 95%CI: 0.74-0.97 per week), small-for-gestational age children (adj OR: 2.11; 95%CI: 1.20-3.72) or children intubated for more than 28 days (adj OR: 3.16; 95%CI: 1.11-8.98). Altered palatal morphology was more common in case of cerebral palsy or moderate neuromotor dysfunction assessed at 5 years. Results were basically the same when neuromotor dysfunction was taken into account, except for intubation.

CONCLUSION

Male sex, low gestational age, small-for-gestational age and long intubation have been identified as probable neonatal risk factors for alteration of palatal morphology at 5 years of age in very preterm children. Further studies are needed to confirm these results.

Impact of Perinatal Different Intrauterine Environments on Child Growth and Development in the First Six Months of Life--IVAPSA Birth Cohort: rationale, design, and methods

Background

In the last twenty years, retrospective studies have shown that perinatal events may impact the individual health in the medium and long term. However, only a few prospective studies were designed to address this phenomenon. This study aims to describe the design and methods of the Impact of Perinatal Environmental Variations in the First Six Months of Life - the IVAPSA Birth Cohort.

Method/Design

This is a clinical study and involves the recruitment of a birth cohort from hospitals in Porto Alegre, Rio Grande do Sul, Brazil. Mothers from different clinical backgrounds (hypertensive, diabetics, smokers, having an intrauterine growth restricted child for idiopathic reasons, and controls) will be invited to join the study twenty-four hours after the birth of their child. Data on economic, social, and maternal health care, feeding practices, anthropometric measures, physical activity, and neuropsychological evaluation will be obtained in interviews at postpartum, 7 and 15 days, 1, 3 and 6 months of life.

Discussion

To our knowledge, this is the first thematic cohort focused on the effects of intrauterine growth restriction to prospectively enroll mothers from different clinical backgrounds. The IVAPSA Birth Cohort is a promising research platform that can contribute to the knowledge on the relationship between perinatal events and their consequences on the children's early life.

Neonatal assessments for the preterm infant up to 4 months corrected age: a systematic review

AIM

The aim of this study was to systematically review the clinimetric properties of longitudinal neonatal neurobehavioural and neuromotor assessments for preterm infants.

METHOD

Twenty-seven assessment measures were identified. The following eight measures met the study inclusion criteria: Assessment of Preterm Infants' Behaviour (APIB), Neonatal Intensive Care Unit Network Neurobehavioural Scale (NNNS), Test of Infant Motor Performance (TIMP), Prechtl's Assessment of General Movements (GMs), Neurobehavioural Assessment of the Preterm Infant (NAPI), Dubowitz Neurological Assessment of the Preterm and Full-term Infant (Dubowitz), Neuromotor Behavioural Assessment (NMBA), and the Brazelton Neonatal Behavioural Assessment Scale (NBAS). The primary purposes included prediction (TIMP, GMs, Dubowitz), discrimination (all assessments), and evaluation of change (TIMP, NAPI). Measures of assessment were included in the study if they were (1) primarily neurobehavioural or neuromotor assessments that were suitable for use with preterm infants (<37 weeks gestation) up to 4 months corrected age and were discriminative, predictive, or evaluative; (2) standardized procedures designed for serial/longitudinal use; or (3) criterion or norm referenced. However, all assessment tools that were not published in English in a peer-reviewed journal or were primarily neurological assessments, one-time evaluations, screening tools, or not commercially available were not used.

RESULTS

All of the measures included in the review demonstrated adequate content and construct validity. Concurrent validity was reported for APIB, NNNS, Dubowitz, and GMs. Predictive validity was high for GMs with studies reporting up to 100% senstivity for predicting cerebral palsy at the age of 12 to 24 months. Interrater reliability was strong for the TIMP (intraclass correlation=0.95), GMs (K=0.8), and moderate for the NAPI (r=0.67-0.97). Clinical utility was variable for ease of scoring, interpretability, cost, and access.

INTERPRETATION

In the absence of a criterion standard for neonatal neuromotor assessments, the NNNS and APIB have strong psychometric qualities with better utility for research. Similarly, the GMs, TIMP, and NAPI have strong psychometric qualities but better utility for clinical settings. The GMs has best prediction of future outcome and the TIMP has best evaluative validity.

Unbound bilirubin does not increase during ibuprofen treatment of patent ductus arteriosus in preterm infants

OBJECTIVE

To determine whether ibuprofen displaces bilirubin from albumin in preterm infants.

STUDY DESIGN

A total of 34 preterm neonates (<32 weeks gestation) treated by ibuprofen (10-5-5 mg/kg) were included in this prospective open-label study. Total bilirubin (TB), unbound bilirubin (UB), and ibuprofen concentrations were measured before, 1 hour, and 6 hours after the first dose; before and 1 hour after the second dose; and 72 hours after the beginning of treatment. The infants were screened by auditory brainstem responses and by neurologic examination at term.

RESULTS

At baseline, TB, UB, apparent binding affinity of albumin (Ka), and albumin concentrations were 6.0±1.6 mg/dL, 1.9±2.2 μg/dL, 14.1±5.8 L·μmol(-1), and 28.7±2.3 g/L, respectively. Ibuprofen treatment had no effect on TB, UB, or Ka values. No correlation between UB or Ka and ibuprofen concentrations was found. No neurologic symptoms or significant modifications of auditory brainstem responses were observed at term.

CONCLUSION

Ibuprofen (10-5-5 mg/kg) did not displace bilirubin in preterm infants with a baseline TB concentration <8.8 mg/dL.

Prediction of developmental performance in preterm infants at two years of corrected age: contribution of the neurological assessment at term age

BACKGROUND

The population of preterm infants is increasing and resources available for follow-up are limited. Early markers are needed to identify children who will show major as well as more subtle neurodevelopmental impairments. Such a challenge could be achieved with the Amiel-Tison Neurological Assessment at Term (ATNAT).

AIMS

This study assesses the usefulness of the ATNAT in the prediction of developmental problems at two years of corrected age (CA) in infants born between 29 and 37 weeks of gestation.

METHOD

Inclusion criteria were: gestational age between 29(0/7) and 36(6/7) weeks inclusively, birth weight below 2500g and minimal 24-hour stay in the Neonatal Intensive Care Unit of Sainte-Justine Hospital. A sample of 147 was prospectively recruited and assessed at two ages: at term with the ATNAT and at 24months CA with Bayley Scales of Infant Development-II.

RESULTS

No major impairment such as cerebral palsy and no neurosensory impairment were observed. Developmental delay defined by an index<70 on the mental or psychomotor scale was reported respectively in 6.2% and 5.4% of the cohort. Significant differences in mental, psychomotor and behavioral performances were found according to neurological status. Neurological status was the only variable to enter the predictive model for psychomotor and behavioral indexes. Gender and neurological status remained in the predictive model for mental performance.

CONCLUSION

This study supports the inclusion of the ATNAT among the eligibility criteria for systematic neurodevelopmental surveillance as it allows early identification of infants at higher risk of low developmental performances at 24months CA.

Electrophysiological auditory responses and language development in infants with periventricular leukomalacia

This study presents evidence suggesting that electrophysiological responses to language-related auditory stimuli recorded at 46weeks postconceptional age (PCA) are associated with language development, particularly in infants with periventricular leukomalacia (PVL). In order to investigate this hypothesis, electrophysiological responses to a set of auditory stimuli consisting of series of syllables and tones were recorded from a population of infants with PVL at 46weeks PCA. A communicative development inventory (i.e., parent report) was applied to this population during a follow-up study performed at 14months of age. The results of this later test were analyzed with a statistical clustering procedure, which resulted in two well-defined groups identified as the high-score (HS) and low-score (LS) groups. The event-induced power of the EEG data recorded at 46weeks PCA was analyzed using a dimensionality reduction approach, resulting in a new set of descriptive variables. The LS and HS groups formed well-separated clusters in the space spanned by these descriptive variables, which can therefore be used to predict whether a new subject will belong to either of these groups. A predictive classification rate of 80% was obtained by using a linear classifier that was trained with a leave-one-out cross-validation technique.

[Neuroprotection with hypothermia in the newborn with hypoxic-ischaemic encephalopathy. Standard guidelines for its clinical application]

Standardisation of hypothermia as a treatment for perinatal hypoxic-ischaemic encephalopathy is supported by current scientific evidence. The following document was prepared by the authors on request of the Spanish Society of Neonatology and is intended to be a guide for the proper implementation of this therapy. We discuss the difficulties that may arise when moving from the strict framework of clinical trials to clinical daily care: early recognition of clinical encephalopathy, inclusion and exclusion criteria, hypothermia during transport, type of hypothermia (selective head or systemic cooling) and side effects of therapy. The availability of hypothermia therapy has changed the prognosis of children with hypoxic-ischaemic encephalopathy and our choices of therapeutic support. In this sense, it is especially important to be aware of the changes in the predictive value of the neurological examination and the electroencephalographic recording in cooled infants. In order to improve neuroprotection with hypothermia we need earlier recognition of to recognise earlier the infants that may benefit from cooling. Biomarkers of brain injury could help us in the selection of these patients. Every single infant treated with hypothermia must be included in a follow up program in order to assess neurodevelopmental outcome.

Neurological evaluation of newborn infants of mothers working in citrus groves in Northern Thailand

The purpose of this pilot study was to assess neurological function in newborn infants born to mothers working in citrus orchards in Northern Thailand for a period in excess of one year where pesticide applications average 35 times a year. Forty-one infants from uncomplicated term births at the community hospital in Fang, Thailand, were given neurological evaluations during the first four days of life. This was a cross-sectional study in which nine mothers worked in citrus orchards and 32 mothers did not. Examiners were not given the exposure history of the mothers. Twelve infants--five of them born to mothers from citrus orchards--had examinations demonstrating abnormal muscle tone. Using logistic regression, the final model showed that maternal citrus grove exposure and anesthesia use were significant predictors (p < 0.05) of abnormal muscle tone with adjusted odds ratios of 9.82 (CI = 1.42, 68.07) and 5.99 (CI = 1.003, 35.85) for exposure and anesthesia respectively.

Nucleated red blood cells and early EEG: predicting Sarnat stage and two year outcome

AIMS

Hypoxic Ischaemic Encephalopathy (HIE) causes characteristic changes of the electroencephalogram (EEG), and a raised Nucleated Red Blood Cell (NRBC) count compared to controls. We wished to examine whether combining these markers could improve their ability to predict HIE severity in the first 24h.

METHODS

Term infants with HIE were recruited. NRBC count and continuous multi-channel EEG were recorded within the first 24h. Neurological assessment was carried out at 24 months. A control population with NRBC counts in the first 24h was recruited.

RESULTS

44 infants with HIE and 43 control infants were recruited. Of the HIE population 39 completed a 2 year follow-up. The median NRBC count differed significantly between the controls and those with HIE (3/100 WBC [range of 0-11] vs 12.3/100 WBC [0-240]) (p<0.001). Within the HIE population the median NRBC count was significantly greater in infants with moderate/severe HIE than mild (16/100 WBC [range of 0-240] vs 8/100 WBC [1-23]) (p=0.016), and among infants with abnormal outcome compared to normal (21.3/100 WBC [1-239.8] vs 8.3/100 WBC [0-50])(p=0.03). The predictive ability of EEG changed with time post-delivery, therefore results are given at both 12 and 24h of age. At both time points the combined marker had a stronger correlation than EEG alone; with HIE severity (12h: r=0.661 vs r=0.622), (24h: r=0.645 vs r=0.598), and with outcome at 2 years (12h: r=0.756 vs r=0.652), (24h: r=0.802 vs r=0.746).

CONCLUSION

Combining early EEG and NRBC count to predict HIE severity and neurological outcome, improved the predictive ability of either in isolation.