Intraventricular hemorrhage and developmental outcomes at 24 months of age in extremely preterm infants

Isolated Cystic Periventricular Leukomalacia Differs from Cystic Periventricular Leukomalacia with Intraventricular Hemorrhage in Prevalence, Risk Factors and Outcomes in Preterm Infants

BACKGROUND

Cystic periventricular leukomalacia (cPVL) is the most severe white matter injury and is often associated with intraventricular hemorrhage (IVH) in preterm infants.

OBJECTIVE

The aim of this study was to investigate the prevalence, risk factors and neurodevelopmental outcomes of isolated cPVL and cPVL with low-grade and high-grade IVH in premature infants.

METHODS

From 2001 to 2012, 9,964 infants with <31 weeks' gestational age (GA) admitted to Taiwan hospitals were enrolled. cPVL was classified into three groups: isolated cPVL, cPVL with low-grade (I/II) IVH, and cPVL with high-grade (III) IVH.

RESULTS

Of 7,805 infants with complete ultrasound data, 286 (3.7%) had cPVL. Among the cPVL infants, 93 (32.5%) were isolated, 118 (41.3%) had low-grade IVH and 75 (26.2%) had high-grade IVH. The risk of cPVL with IVH was significantly higher among infants with <27 weeks' GA than those with ≥27 weeks' GA, in contrast to that of isolated cPVL. Using infants without cPVL and IVH as the reference group, the most significant predictor of isolated cPVL was neonatal sepsis (odds ratio 2.39; 95% confidence interval 1.52-3.77), while 5-min Apgar score <5 (2.50; 1.48-4.21) and prolonged mechanical ventilation (2.19; 1.42-3.42) were associated with cPVL with low-grade IVH, and GA <27 weeks (2.63; 1.56-4.42), pneumothorax (3.04; 1.40-6.65) and prolonged mechanical ventilation (3.36; 1.88-6.01) contributed to cPVL with high-grade IVH. cPVL infants with low-grade and high-grade IVH had a higher risk of abnormal neurodevelopmental outcomes than infants with isolated cPVL at the age of 24 months.

CONCLUSIONS

Isolated cPVL, cPVL with low-grade IVH and cPVL with high-grade IVH had different risk factors and neurodevelopmental outcomes, suggestive of different causal pathways.

Changing definitions of long-term follow-up: Should "long term" be even longer?

There have been amazing changes in outcomes of preterm (PT) infants in the past decades. Whereas early studies reported only survival rates, Dr. Julius Hess published the first outcome study of PT infants in Chicago in 1953. Dr. Lubchenco then published the 10-year follow-up of premature infants born in 1947-1953 and identified a 68% handicap rate. As a result of these early studies, the importance of evaluating NICU graduates both for surveillance and as an outcome of trials was recognized. During the 1970s, there was a gradual expansion in the number of follow-up programs in the United States (US) with an increasing number of follow-up studies published. In the 1980s, the importance of multicenter clinical research networks was recognized and the NICHD Neonatal Research Network (NRN) was initiated in 1986. Follow-up protocols, definitions, and outcomes have evolved over the last 30 years and will be reviewed with a focus on NICHD NRN studies.

The Neurological Outcome of Isolated PVL and Severe IVH in Preterm Infants: Is It Fair to Compare?

OBJECTIVE

We compared the neurological outcome of isolated periventricular leukomalacia and severe intraventricular hemorrhage in a cohort of very low birth weight infants born and managed at single tertiary-care center in Saudi Arabia.

METHODS

We undertook a descriptive retrospective chart review of the neurological status of very low birth weight infants who were born and managed over a 5-year period at King Abdulaziz Medical City, Riyadh. The neurological outcome of neonates with isolated periventricular leukomalacia and severe intraventricular hemorrhage (grades III and IV) was studied and compared in relation to developmental delay and cerebral palsy.

RESULTS

A total of 20 patients with isolated periventricular leukomalacia and 26 with severe intraventricular hemorrhage (grades III and IV) were identified for this study. Of 20 patients with isolated periventricular leukomalacia, 9 (45%) had good developmental outcome and 11 (55%) had bad developmental outcome. Of 26 patients of severe intraventricular hemorrhage, 14 (54%) had good developmental outcome and 12 (46%) had bad developmental outcome (P = 0.55). Significant motor neurological deficit affecting function is distributed as follows: 11/20 (55%) in the isolated periventricular leukomalacia group and 7/26 (27%) in the severe intraventricular hemorrhage group (P = 0.05). Cerebral palsy was diplegic in 7/11 (64%) and quadriplegic in 4/11 (36%) in the isolated periventricular leukomalacia group, and hemiplegic 3/7 (43%), diplegic in 1/7 (14%), and quadriplegic in 3/7 (43%) in the severe intraventricular hemorrhage group (P = 0.03). Distribution of the neurological outcome according to periventricular leukomalacia grade was as follows: for periventricular leukomalacia grade I (n = 8), 6/8 (75%) had good neurological outcome and 2/8 (25%) had bad neurological outcome. In periventricular leukomalacia grade II (n = 4), good neurological outcome was seen in three patients (75%) and bad neurological outcome was seen in one patient (25%). All patients (n = 8) with periventricular leukomalacia grade III had bad outcome (P < 0.01).

CONCLUSION

About half of patients with isolated periventricular leukomalacia and severe intraventricular hemorrhage had a poor developmental outcome. However, the severity of cerebral palsy was greater in the isolated periventricular leukomalacia patients and correlates highly with periventricular leukomalacia grade. Symmetrical diplegic cerebral palsy is the most common motor deficit associated with isolated periventricular leukomalacia, whereas asymmetrical hemiplegic cerebral palsy is seen exclusively with severe intraventricular hemorrhage.

Newborn hearing screening programme in Belgium: a consensus recommendation on risk factors

Background

Understanding the risk factors for hearing loss is essential for designing the Belgian newborn hearing screening programme. Accordingly, they needed to be updated in accordance with current scientific knowledge. This study aimed to update the recommendations for the clinical management and follow-up of newborns with neonatal risk factors of hearing loss for the newborn screening programme in Belgium.

Methods

A literature review was performed, and the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system assessment method was used to determine the level of evidence quality and strength of the recommendation for each risk factor. The state of scientific knowledge, levels of evidence quality, and graded recommendations were subsequently assessed using a three-round Delphi consensus process (two online questionnaires and one face-to-face meeting).

Results

Congenital infections (i.e., cytomegalovirus, toxoplasmosis, and syphilis), a family history of hearing loss, consanguinity in (grand)parents, malformation syndromes, and foetal alcohol syndrome presented a ‘high’ level of evidence quality as neonatal risk factors for hearing loss. Because of the sensitivity of auditory function to bilirubin toxicity, hyperbilirubinaemia was assessed at a ‘moderate’ level of evidence quality. In contrast, a very low birth weight, low Apgar score, and hospitalisation in the neonatal intensive care unit ranged from ‘very low’ to ‘low’ levels, and ototoxic drugs were evidenced as ‘very low’. Possible explanations for these ‘very low’ and ‘low’ levels include the improved management of these health conditions or treatments, and methodological weaknesses such as confounding effects, which make it difficult to conclude on individual risk factors. In the recommendation statements, the experts emphasised avoiding unidentified neonatal hearing loss and opted to include risk factors for hearing loss even in cases with weak evidence. The panel also highlighted the cumulative effect of risk factors for hearing loss.

Conclusions

We revised the recommendations for the clinical management and follow-up of newborns exhibiting neonatal risk factors for hearing loss on the basis of the aforementioned evidence-based approach and clinical experience from experts. The next step is the implementation of these findings in the Belgian screening programme.

Electronic supplementary material

The online version of this article (doi:10.1186/s12887-015-0479-4) contains supplementary material, which is available to authorized users.

Do normal head ultrasounds need repeating in infants less than 30 weeks gestation?

OBJECTIVE

Current head ultrasound (HUS) screening recommendations in preterm infants often include a repeat HUS, regardless of initial findings. The objective of this study is to determine the rate of subsequent severe intraventricular hemorrhage (IVH), ventriculomegaly (VM), or periventricular leukomalacia (PVL) among infants < 30 weeks gestation (EGA) with a normal HUS at day of life (DOL) 4-10.

METHODS

Retrospectively collected data were analyzed for all infants < 30 weeks EGA cared for in one NICU from 1 January 2010 to 31 August 2014. Infants with severe congenital anomalies were excluded. We reviewed the first three HUSs and last documented HUS. Severe IVH was defined as > Papile grade 2 and significant interval HUS change was defined as development of severe IVH, PVL, or VM.

RESULTS

Of the 383 infants who had an initial screening HUS between DOL 4 and 10, 258 (67%) were initially normal and repeat screening was performed in 228 of these. None developed severe IVH on follow-up HUS. One infant developed VM secondary to GBS meningitis, and one developed echogenicity concerning for PVL that later resolved.

CONCLUSIONS

Among very preterm infants with a normal HUS between DOL 4 and 10, routine follow-up HUS is unlikely to identify a significant change.

Factors associated with feeding progression in extremely preterm infants

BACKGROUND

Among infants born prematurely, competence at oral feeding is necessary for growth and hospital discharge. Extremely preterm (EP) infants (28 weeks of gestational age [GA]) are at risk for a variety of medical complications, which can limit the infant's capacity to develop oral feeding competence.

OBJECTIVE

This study examined feeding progression by assessing timing of acquisition of five early feeding milestones among EP infants and the impact of immaturity and medical complications.

DESIGN

A chart review was conducted for 94 EP infants who participated in a larger longitudinal randomized study. Feeding progression was defined as infants' postmenstrual age (PMA) at five milestones: first enteral feeding, full enteral feeding, first oral feeding, half oral feeding, and full oral feeding. GA at birth and five medical complications (neurological risk, bronchopulmonary dysplasia, necrotizing enterocolitis, patent ductus arteriosus, and gastroesophageal reflux disease) were used as potential factors influencing the feeding progression. Linear mixed models were used to examine feeding progression across the milestones and contributions of GA at birth and five medical complications on the progression, after controlling for milk type as a covariate.

RESULT

EP infants gradually achieved feeding milestones; however, the attainment of the feeding milestones slowed significantly for infants with younger GA at birth and the presence of medical complications, including neurological risk, bronchopulmonary dysplasia, necrotizing enterocolitis, and patent ductus arteriosus but not gastroesophageal reflux disease. Milk type was a significant covariate for all analyses, suggesting that infants fed with breast milk achieved each of five milestones earlier than formula-fed infants.

DISCUSSION

Improved understanding of the timing of essential feeding milestones among EP infants and the contribution of specific medical conditions to the acquisition of these milestones may allow for more targeted care to support feeding skill development.

Neuroimaging and neurodevelopmental outcome in extremely preterm infants

BACKGROUND

Extremely preterm infants are at risk for neurodevelopmental impairment (NDI). Early cranial ultrasound (CUS) is usual practice, but near-term brain MRI has been reported to better predict outcomes. We prospectively evaluated MRI white matter abnormality (WMA) and cerebellar lesions, and serial CUS adverse findings as predictors of outcomes at 18 to 22 months' corrected age.

METHODS

Early and late CUS, and brain MRI were read by masked central readers, in a large cohort (n = 480) of infants <28 weeks' gestation surviving to near term in the Neonatal Research Network. Outcomes included NDI or death after neuroimaging, and significant gross motor impairment or death, with NDI defined as cognitive composite score <70, significant gross motor impairment, and severe hearing or visual impairment. Multivariable models evaluated the relative predictive value of neuroimaging while controlling for other factors.

RESULTS

Of 480 infants, 15 died and 20 were lost. Increasing severity of WMA and significant cerebellar lesions on MRI were associated with adverse outcomes. Cerebellar lesions were rarely identified by CUS. In full multivariable models, both late CUS and MRI, but not early CUS, remained independently associated with NDI or death (MRI cerebellar lesions: odds ratio, 3.0 [95% confidence interval: 1.3-6.8]; late CUS: odds ratio, 9.8 [95% confidence interval: 2.8-35]), and significant gross motor impairment or death. In models that did not include late CUS, MRI moderate-severe WMA was independently associated with adverse outcomes.

CONCLUSIONS

Both late CUS and near-term MRI abnormalities were associated with outcomes, independent of early CUS and other factors, underscoring the relative prognostic value of near-term neuroimaging.

Erythropoietin for the Repair of Cerebral Injury in Very Preterm Infants (EpoRepair)

BACKGROUND

Preterm infants suffering from intraventricular hemorrhage (IVH) are at increased risk for neurodevelopmental impairment. Observational data suggest that recombinant human erythropoietin (rEPO) improves long-term cognitive outcome in infants with IVH. Recent studies revealed a beneficial effect of early high-dose rEPO on white matter development in preterm infants determined by magnetic resonance imaging (MRI).

OBJECTIVES

To summarize the current evidence and to delineate the study protocol of the EpoRepair trial (Erythropoietin for the Repair of Cerebral Injury in Very Preterm Infants).

METHODS

The study involves a review of the literature and the design of a double-blind, placebo-controlled, multicenter trial of repetitive high-dose rEPO administration, enrolling 120 very preterm infants with moderate-to-severe IVH diagnosed by cranial ultrasound in the first days of life, qualitative and quantitative MRI at term-equivalent age and long-term neurodevelopmental follow-up until 5 years of age.

RESULTS AND CONCLUSIONS

The hypothesis generated by observational data that rEPO may improve long-term cognitive outcomes of preterm infants suffering from IVH are to be confirmed or refuted by the randomized controlled trial, EpoRepair.

Impaired white matter development in extremely low-birth-weight infants with previous brain hemorrhage

BACKGROUND AND PURPOSE

Brain hemorrhage is common in premature infants. The purpose of the study is to evaluate white matter development in extremely low-birth-weight infants with or without previous brain hemorrhage.

MATERIALS AND METHODS

Thirty-three extremely low-birth-weight infants were prospectively enrolled and included in this institutional review board-approved study. Another 10 healthy term infants were included as controls. The medical records of the extremely low-birth-weight infants were reviewed for sonography diagnosis of intraventricular hemorrhage. All infants had an MR imaging examination at term-equivalent age for detection of previous hemorrhage, and their white matter was scored and compared among different groups. DTI measured fractional anisotropy values were also compared voxelwise by tract-based spatial statistics.

RESULTS

Compared with controls, the white matter score was not significantly different in extremely low-birth-weight infants without blood deposition on MR imaging (P = .17), but was significantly worse in extremely low-birth-weight infants with blood deposition on MR imaging but no intraventricular hemorrhage diagnosis by sonography (P = .02), in extremely low-birth-weight infants with grade 1 or 2 intraventricular hemorrhage on sonography (P = .003), and in extremely low-birth-weight infants with grade 3 or 4 intraventricular hemorrhage on sonography (P = .0001). Extremely low-birth-weight infants without blood deposition on MR imaging did not show any white matter regions with significantly lower fractional anisotropy values than controls. Extremely low-birth-weight infants with blood deposition on MR imaging, but no intraventricular hemorrhage diagnosis, did show white matter regions with significantly lower fractional anisotropy values, and extremely low-birth-weight infants with intraventricular hemorrhage diagnosis had widespread white matter regions with lower fractional anisotropy values.

CONCLUSIONS

Previous brain hemorrhage is associated with abnormal white matter in extremely low-birth-weight infants at term-equivalent age, and sonography is not sensitive to minor hemorrhages that are sufficient to cause white matter injury.

Timing of cord clamping in very preterm infants: more evidence is needed

In December 2012, the American College of Obstetricians and Gynecologists published a Committee Opinion entitled "Timing of umbilical cord clamping after birth." It stated that "evidence exists to support delayed cord clamping in preterm infants, when feasible. The single most important benefit for preterm infants is the possibility for a nearly 50% reduction in IVH." However, the Committee Opinion added that the ideal timing of umbilical cord clamping has yet to be determined and recommended that large clinical trials be conducted in the most preterm infants. Published randomized controlled trials include <200 infants of <30 weeks' gestation, with assessments of neurodevelopmental outcome in less than one-half of the children. This is a major gap in the evidence. Without reliable data from randomized controlled trials that optimally include childhood follow-up evaluations, we will not know whether delayed cord clamping may do more overall harm than good. Ongoing trials of delayed cord clamping plan to report childhood outcomes in >2000 additional very preterm infants. Current recommendations may need to change when these results become available. Greater international collaboration could accelerate resolution of whether this promising intervention will improve disability-free survival in about 1 million infants who will be born very preterm globally each year.

Language, motor and cognitive development of extremely preterm children: modeling individual growth trajectories over the first three years of life

Survival rate of extremely low gestational age (ELGA) newborns has increased over 80% in the last 15 years, but its consequences on the short- and longer-term developmental competencies may be severe. The aim of this study was to describe growth trajectories of linguistic, motor and cognitive skills among ELGA children, compared to full-term (FT) peers, from the first to the third year of life, a crucial period for development. Growth curve analysis was used to examine individual and group differences in terms of initial status at 12 months and rate of growth through the second and the third year of life with five points of assessment. Twenty-eight monolingual Italian children, of whom 17 were ELGA (mean GA 25.7 weeks) and 11 were FT children, were assessed through the BSID-III at 12, 18, 24, 30 and 36 months for language skills and at 12, 24 and 30 months for motor and cognitive skills. ELGA children presented significantly lower scores than FT peers in language, motor and cognitive skills and they did not overcome their disadvantage by 3 years, even if their corrected age was taken into account. Concerning growth curves, in motor development a significant increasing divergence was found showing a Matthew effect with the preterm sample falling further behind the FT sample. In linguistic and cognitive development, instead, a stable gap between the two samples was found. In addition, great inter-individual differences in rate of change were observed for language development in both samples. Our findings highlight the theoretical and clinical relevance of analyzing, through growth curve analyses, the developmental trajectories of ELGA children in language skills taking into account their inter-individual variability also across motor and cognitive domains.

LEARNING OUTCOMES

After reading this article, the reader will interpret: (a) characteristics and growth trajectories of ELGA children from the first to the third year of life with respect to FT children in language, motor and cognitive development; (b) the method of growth curve analyses to describe group as well as inter-individual trajectories; (c) the rate of inter-individual variability in language as well as motor and cognitive skills, which gives useful indications for early interventions.

Outcomes of extremely preterm infants following severe intracranial hemorrhage

OBJECTIVE

Severe intracranial hemorrhage (ICH) is an important prognostic variable in extremely preterm (EPT) infants. We examined imaging and clinical variables that predict outcomes in EPT infants with severe ICH.

STUDY DESIGN

Retrospective analysis of 353 EPT infants with severe ICH. Outcomes were compared by examining: (i) unilateral vs bilateral ICH; and (ii) presence vs absence of hemorrhagic parenchymal infarction (HPI). Regression analyses identified variables associated with death or neurodevelopmental impairment (NDI).

RESULT

Bilateral ICH and HPI had higher rates of adverse outcomes and were independently associated with death/NDI. HPI was the most important variable for infants of lower birth weight, and bilateral ICH for larger infants. For infants surviving to 36 weeks, shunt placement was most associated with death/NDI.

CONCLUSION

Bilateral ICH and the presence of HPI in EPT infants with severe ICH are associated with death/NDI, though the importance depends on birth weight and survival to 36 weeks.

ECLS for preemies: the artificial placenta

The high mortality and morbidity associated with respiratory failure among extremely low gestational age newborns (ELGANs) remains an unsolved problem. A logical strategy to avoid these complications would involve re-creating the intrauterine environment with extracorporeal membrane oxygenation (ECMO) instead of mechanical ventilation. Such a device, termed an artificial placenta, was first researched over 50 years ago. AP models vary, but all incorporate ECMO involving the umbilical vessels, lack of mechanical ventilation, and low partial pressure of oxygen to preserve fetal circulation. Current research has focused on low-volume pumpless arteriovenous circuits as well as pump-driven venovenous circuits.

Intraventricular hemorrhage and neurodevelopmental outcomes in extreme preterm infants

OBJECTIVE

Not many large studies have reported the true impact of lower-grade intraventricular hemorrhages in preterm infants. We studied the neurodevelopmental outcomes of extremely preterm infants in relation to the severity of intraventricular hemorrhage.

METHODS

A regional cohort study of infants born at 23 to 28 weeks' gestation and admitted to a NICU between 1998 and 2004. Primary outcome measure was moderate to severe neurosensory impairment at 2 to 3 years' corrected age defined as developmental delay (developmental quotient >2 SD below the mean), cerebral palsy, bilateral deafness, or bilateral blindness.

RESULTS

Of the 1472 survivors assessed, infants with grade III-IV intraventricular hemorrhage (IVH; n = 93) had higher rates of developmental delay (17.5%), cerebral palsy (30%), deafness (8.6%), and blindness (2.2%). Grade I-II IVH infants (n = 336) also had increased rates of neurosensory impairment (22% vs 12.1%), developmental delay (7.8% vs 3.4%), cerebral palsy (10.4% vs 6.5%), and deafness (6.0% vs 2.3%) compared with the no IVH group (n = 1043). After exclusion of 40 infants with late ultrasound findings (periventricular leukomalacia, porencephaly, ventricular enlargement), isolated grade I-II IVH (n = 296) had increased rates of moderate-severe neurosensory impairment (18.6% vs 12.1%). Isolated grade I-II IVH was also independently associated with a higher risk of neurosensory impairment (adjusted odds ratio 1.73, 95% confidence interval 1.22-2.46).

CONCLUSIONS

Grade I-II IVH, even with no documented white matter injury or other late ultrasound abnormalities, is associated with adverse neurodevelopmental outcomes in extremely preterm infants.

Systemic inflammation, intraventricular hemorrhage, and white matter injury

To see if the systemic inflammation profile of 123 infants born before the 28th week of gestation who had intraventricular hemorrhage without white matter injury differed from that of 68 peers who had both lesions, we compared both groups to 677 peers who had neither. Cranial ultrasound scans were read independently by multiple readers until concordance. The concentrations of 25 proteins were measured with multiplex arrays using an electrochemiluminescence system. Infants who had both hemorrhage and white matter injury were more likely than others to have elevated concentrations of C-reactive protein and interleukin 8 on days 1, 7, and 14, and elevated concentrations of serum amyloid A and tumor necrosis factor-α on 2 of these days. Intraventricular hemorrhage should probably be viewed as 2 entities: hemorrhage alone and hemorrhage with white matter injury. Each entity is associated with inflammation, but the combination has a stronger inflammatory signal than hemorrhage alone.

Antecedents of perinatal cerebral white matter damage with and without intraventricular hemorrhage in very preterm newborns

BACKGROUND

Isolated periventricular leukomalacia, defined as periventricular leukomalacia unaccompanied by intraventricular hemorrhage, is reportedly increased in newborns with systemic hypotension and in infants who received treatment for systemic hypotension or a patent ductus arteriosus.

METHODS

This study sought to determine if the risk profile of one or more hypoechoic lesions unaccompanied by intraventricular hemorrhage, our surrogate for isolated periventricular leukomalacia, differs from that of one or more hypoechoic lesions preceded or accompanied by intraventricular hemorrhage. We compared extremely preterm infants (i.e., gestation 23-27 weeks) with each of these entities to 885 extremely preterm infants who had neither an isolated hypoechoic lesion nor a hypoechoic lesion preceded or accompanied by intraventricular hemorrhage.

RESULTS

The risk of a hypoechoic lesion with intraventricular hemorrhage (N = 61) was associated with gestation <25 weeks, high Score for Acute Neonatal Physiology, early recurrent or prolonged acidemia, analgesic exposure, and mechanical ventilation 1 week after birth.

CONCLUSIONS

In this large, multicenter sample of extremely low gestational age newborns, the risk profile of a hypoechoic lesion unaccompanied by intraventricular hemorrhage differed from that of a hypoechoic lesion with intraventricular hemorrhage. This suggests that hypoechoic lesions accompanied or preceded by intraventricular hemorrhage (our surrogate for periventricular hemorrhagic infarction) may have a different causal pathway than hypoechoic lesions without intraventricular hemorrhage, our surrogate for periventricular leukomalacia.

Imaging the premature brain: ultrasound or MRI?

Neuroimaging of preterm infants has become part of routine clinical care, but the question is often raised on how often cranial ultrasound should be done and whether every high risk preterm infant should at least have one MRI during the neonatal period. An increasing number of centres perform an MRI either at discharge or around term equivalent age, and a few centres have access to a magnet in or adjacent to the neonatal intensive care unit and are doing sequential MRIs. In this review, we try to discuss when best to perform these two neuroimaging techniques and the additional information each technique may provide.

A phase II randomized clinical trial on cerebral near-infrared spectroscopy plus a treatment guideline versus treatment as usual for extremely preterm infants during the first three days of life (SafeBoosC): study protocol for a randomized controlled trial

Background

Every year in Europe about 25,000 infants are born extremely preterm. These infants have a 20% mortality rate, and 25% of survivors have severe long-term cerebral impairment. Preventative measures are key to reduce mortality and morbidity in an extremely preterm population. The primary objective of the SafeBoosC phase II trial is to examine if it is possible to stabilize the cerebral oxygenation of extremely preterm infants during the first 72 hours of life through the application of cerebral near-infrared spectroscopy (NIRS) oximetry and implementation of an clinical treatment guideline based on intervention thresholds of cerebral regional tissue saturation rStO₂.

Methods/Design

SafeBoosC is a randomized, blinded, multinational, phase II clinical trial. The inclusion criteria are: neonates born more than 12 weeks preterm; decision to conduct full life support; parental informed consent; and possibility to place the cerebral NIRS oximeter within 3 hours after birth. The infants will be randomized into one of two groups. Both groups will have a cerebral oximeter monitoring device placed within three hours of birth. In the experimental group, the cerebral oxygenation reading will supplement the standard treatment using a predefined treatment guideline. In the control group, the cerebral oxygenation reading will not be visible and the infant will be treated according to the local standards. The primary outcome is the multiplication of the duration and magnitude of rStO₂ values outside the target ranges of 55% to 85%, that is, the ‘burden of hypoxia and hyperoxia’ expressed in ‘%hours’. To detect a 50% difference between the experimental and control group in %hours, 166 infants in total must be randomized. Secondary outcomes are mortality at term date, cerebral ultrasound score, and interburst intervals on an amplitude-integrated electroencephalogram at 64 hours of life and explorative outcomes include neurodevelopmental outcome at 2 years corrected age, magnetic resonance imaging at term, blood biomarkers at 6 and 64 hours after birth, and adverse events.

Discussion

Cerebral oximetry guided interventions have the potential to improve neurodevelopmental outcome in extremely preterm infants. It is a logical first step to test if it is possible to reduce the burden of hypoxia and hyperoxia.

Trial registration

ClinicalTrial.gov, NCT01590316

Reliability and Applicability of the Bayley Scale of Infant Development-II for Children With Cerebral Palsy

Objective

To obtain reliability and applicability of the Korean version Bayley Scale of Infant Development-II (BSID-II) in evaluating the developmental status of children with cerebral palsy (CP).

Methods

The inter-rater reliability of BSID-II scores from 68 children with CP (46 boys and 22 girls; mean age, 32.54±16.76 months; age range, 4 to 78 months) was evaluated by 10 pediatric occupational therapists. Patients were classified in several ways according to age group, typology, and the severity of motor impairment by the level of the Gross Motor Function Classification System (GMFCS). The measures were performed by video analysis, and the results of intraclass correlation (ICC) were obtained for each of the above classifications. To evaluate the clinical applicability of BSID-II for CP, its correlation with the Gross Motor Function Measure (GMFM), which has been known as the standard motor assessment for CP, was investigated.

Results

ICC was 0.99 for the Mental scale and 0.98 for the Motor scale in all subjects. The values of ICC ranged from 0.92 to 0.99 for each age group, 0.93 to 0.99 for each typology, and 0.99 to 1.00 for each GMFCS level. A strong positive correlation was found between the BSID-II Motor raw score and the GMFM total score (r=0.84, p<0.001), and a moderate correlation was observed between the BSID-II Mental raw score and the GMFM total score (r=0.65, p<0.001).

Conclusion

The Korean version of BSID-II is a reliable tool to measure the functional status of children with CP. The raw scores of BSID-II showed a great correlation with GMFM, indicating validity of this measure for children with CP on clinical basis.

Endoglin in amniotic fluid as a risk factor for the subsequent development of bronchopulmonary dysplasia

OBJECTIVE

Cross-talk between inflammation and angiogenesis pathways has been recently reported. The objectives of this study were to: (i) examine whether amniotic fluid (AF) concentrations of soluble endoglin (sEng), a protein with anti-angiogenic properties, change during pregnancy, parturition, or intra-amniotic infection and/or inflammation (IAI); (ii) determine whether an increase in sEng in the AF of patients with preterm labor (PTL) and preterm prelabor rupture of membranes (PROM) is associated with adverse neonatal outcomes; and (iii) investigate potential sources of sEng in AF.

STUDY DESIGN

A cross-sectional study was conducted to include patients in the following groups: (i) mid-trimester (n = 20); (ii) PTL with term delivery (n = 95); (iii) PTL leading to preterm delivery with (n = 40) and without IAI (n = 46); (iv) preterm PROM with (n = 37) and without IAI (n = 37); (v) term in labor (n = 48) and not in labor (n = 44). AF concentrations of sEng were determined by enzyme-linked immunosorbent assay. Chorioamniotic membranes, umbilical cord blood, and AF macrophages were examined for the expression of endoglin.

RESULTS

(i) Patients with IAI had a higher median AF concentration of sEng than those without IAI (P = 0.02 for PTL and 0.06 for preterm PROM); (ii) AF concentrations of sEng in the 3rd and 4th quartiles were associated with IAI (OR 2.5 and 7.9, respectively); (iii) an AF sEng concentration ≥779.5 pg/mL was associated with bronchopulmonary dysplasia (BPD) (OR 7.9); (iv) endoglin was co-localized with CD14+ macrophages in AF pellets of patients with IAI by immunofluorescence and flow cytometry; and (v) the concentration of sEng in the supernatant was significantly increased after the treatment of macrophages with endotoxin or TNF-α.

CONCLUSIONS

Soluble endoglin participates in the host response against IAI. Activated macrophages may be a source of sEng concentrations in the AF of patients with IAI. An increase of sEng in the AF is associated with BPD and adverse neonatal outcomes.

Birth weight- and fetal weight-growth restriction: impact on neurodevelopment

BACKGROUND

The newborn classified as growth-restricted on fetal weight curves, but not on birth weight curves, is classified prenatally as small for gestational age (SGA), but postnatally as appropriate for gestational age (AGA).

AIMS

To see (1) to what extent the neurodevelopmental outcomes at 24 months corrected age differed among three groups of infants (those identified as SGA based on birth weight curves (B-SGA), those identified as SGA based on fetal weight curves only (F-SGA), and the referent group of infants considered AGA, (2) if girls and boys were equally affected by growth restriction, and (3) to what extent neurosensory limitations influenced what we found.

STUDY DESIGN

Observational cohort of births before the 28th week of gestation.

OUTCOME MEASURES

Mental Development Index (MDI) and Psychomotor Development Index (PDI) of the Bayley Scales of Infant Development II.

RESULTS

B-SGA, but not F-SGA girls were at an increased risk of a PDI<70 (OR=2.8; 95% CI: 1.5, 5.3) compared to AGA girls. B-SGA and F-SGA boys were not at greater risk of low developmental indices than AGA boys. Neurosensory limitations diminished associations among girls of B-SGA with low MDI, and among boys B-SGA and F-SGA with PDI<70.

CONCLUSIONS

Only girls with the most severe growth restriction were at increased risk of neurodevelopmental impairment at 24 months corrected age in the total sample. Neurosensory limitations appear to interfere with assessing growth restriction effects in both girls and boys born preterm.