Effects of intraventricular hemorrhage and socioeconomic status on perceptual, cognitive, and neurologic status of low birth weight infants at 5 years of age

Neurodevelopmental outcomes in preterm or low birth weight infants with germinal matrix-intraventricular hemorrhage: a meta-analysis

BACKGROUND

This meta-analysis aimed to identify the near- and long-term neurodevelopmental prognoses of preterm or low birth weight (LBW) infants with different severities of intraventricular hemorrhage (IVH).

METHODS

Four databases were searched for observational studies that were qualified using the Newcastle-Ottawa Scale.

RESULTS

37 studies involving 32,370 children were included. Compared to children without IVH, children with mild IVH had higher incidences of neurodevelopmental impairment (NDI), cerebral palsy (CP), motor/cognitive delay, hearing impairment and visual impairment, as well as lower scores of the mental development index (MDI) and psychomotor development (PDI). Moreover, compared to mild IVH, severe IVH increased susceptibilities of children to NDI, motor delay, CP, hearing impairment and visual impairment, with worse performances in MDI, PDI, motor score and IQ. Mild IVH was not associated with seizures or epilepsy.

CONCLUSIONS

Adverse neurodevelopmental outcomes positively associated with the occurrence and severity of IVH in preterm or LBW infants, providing evidence for counseling and further decisions regarding early therapeutic interventions.

IMPACT

Adverse neurodevelopmental outcomes later in life were closely associated with the occurrence and severity of IVH in preterm or LBW infants. Our results highlight the importance to make prediction of the neurodevelopmental outcomes of children born preterm or LBW with a history of IVH, which will guide affected parents when their children need clinical interventions to reach the full potential. We emphasize the importance of identifying specific developmental delays that may exist in children with IVH, providing detailed information for the development of comprehensive intervention measures.

Impact of low-grade intraventricular hemorrhage on neurodevelopmental outcome in very preterm infants at two years of age

BACKGROUND

High-grade intraventricular hemorrhage (IVH) in very preterm infants is a known risk factor for adverse neurodevelopmental outcome. Prognosis is less clear for low-grade (grades I/II) IVH however, with conflicting study results in recent years.

OBJECTIVE

To evaluate the impact of low-grade IVH on neurodevelopmental outcome at 2 years corrected age in preterm infants born below 32 weeks gestation at the University hospital of Zurich between 2009 and 2014.

METHODS

Among 843 live-born preterm infants born during the observation period, 509 were included in our study. Exclusion criteria were death, high-grade IVH, cystic periventricular leukomalacia and congenital malformations. Infants were grouped into those with or without low-grade IVH according to cranial ultrasound. Neurodevelopmental impairment (NDI) was defined as cognitive or motor developmental score > 2 standard deviations below the mean and/or CP grades 2-5 and/or moderate/severe vision loss and/or hearing problem corrected with hearing aids. Multivariate linear regression was used to assess effect of low-grade IVH on endpoints while adjusting for other risk factors.

RESULTS

87 preterm infants had low-grade IVH (42 grade I, 45 grade II) on cranial ultrasound. These were compared to 422 preterm infants without IVH. Follow-up rate was 82.4 %. Preterm infants with low-grade IVH had higher rates of NDI (21.8 vs 13.3 %, p = 0.047). Infants with IVH grade II had significantly higher rates for CP (8.9 % vs 3.6 %, p = 0.003), visual impairment (20.5 % vs 8.3 %, p = 0.009) and NDI (33.3 % vs 13.3 %, p < 0.001).

CONCLUSION

In our study, low-grade IVH - and especially IVH grade II - is associated with adverse neurodevelopmental outcome at 2 years of corrected age.

Use of Prophylactic Indomethacin in Preterm Infants: A Systematic Review and Meta-Analysis

BACKGROUND

Prophylactic indomethacin has been widely used as an effective intervention for reducing mortalities and morbidities in preterm infants including the cardiopulmonary and neurodevelopmental morbidities such as intraventricular hemorrhage (IVH), but many studies have reported contradictory outcomes regarding its significance. Therefore, we aim to systematically review and meta-analyze the data of prophylactic indomethacin on preterm infants.

METHODS

Our systematic search included the following databases: Pubmed, Google Scholar, Scopus, Web of Science, The New York Academy of Medicine (NYAM), Virtual health library (VHL), and the System for Information on Grey Literature in Europe (SIGLE) to include studies that assessed the use of prophylactic indomethacin in preterm infants until 12 August 2021.

RESULTS

The final list of our included studies is comprised of 23 randomized trials and cohort studies. Among all the studies outcomes, significant favorable outcome was lowering the rate of PDA, surgical PDA ligation (P < 0.001) and severe IVH (P = 0.008) while no significance was recorded with BPD, pulmonary hemorrhage, intraventricular hemorrhage, necrotizing enterocolitis, intestinal perforation, mortality, and length of hospital stay.

CONCLUSION

Since the meta-analysis results regarding effectiveness of prophylactic indomethacin varied based on the study design particularly with regard to outcomes such as surgical PDA ligation and severe IVH, this warrants the need for more evidence regarding the effectiveness of prophylactic indomethacin in very low birth weight infants.

Follow-Up of Low Birth Weight Preterm Infants After Hospital Discharge: Incidence and Reasons for Rehospitalization

OBJECTIVES

The rehospitalization frequency/indications of low birth weight (LBW) preterms and the effect of rehospitalization on growth and neurodevelopment were investigated.

METHODS

LBW preterms discharged from NICU were prospectively followed until the corrected age of 1 year. Infants rehospitalized after discharge were defined as the study group and those not rehospitalized as the control group. The frequency, duration and etiology of rehospitalization were investigated and the effects of neonatal complications, surgery and socio-demographic status on rehospitalization were assessed.

RESULTS

The study and the control group included 113 and 217 infants, respectively. Infants in the study group were rehospitalized 247 times in total. Rehospitalization was significantly higher in the male gender (39.7% vs. 28.9%, p < 0.05). Hyperbilirubinemia-anemia, anemia-surgery and pulmonary-other infections were the most common indications for rehospitalization in the 0-14 days, 15 days to 2 months and 2-12 months, respectively. Intrauterine growth had no impact on rehospitalization. Somatic growth and neurodevelopment were significantly delayed in the study group (p < 0.05).

CONCLUSION

Birth weight and gestational week are the most important determinants of rehospitalization. Rehospitalized preterm infants have significant deficits in both somatic growth and neurodevelopment despite high-quality follow-up care.

Advances in Management for Preterm Fetuses at Risk of Delivery

Preterm birth accounts for only 11% of live births but contributes to up to 75% of neonatal mortality and more than half of long-term morbidity. Targeted interventions to reduce the most common causes of perinatal morbidity and mortality include intrapartum group B Streptococcus prophylaxis, magnesium sulfate for fetal neuroprotection, antenatal corticosteroids for fetal lung maturity, latency antibiotics for preterm premature rupture of membranes, and tocolysis to allow corticosteroid administration and transfer to a tertiary care center. This article reviews the evidence for interventions to improve outcomes for fetuses at risk for preterm delivery at different gestational ages.

Low-grade intraventricular hemorrhage of preterm infants: neurodevelopmental and motor outcome

Intraventricular hemorrhage (IVH) is a main complication of prematurity, inversely associated with gestational age and birth weight. Low-grade IVH (I and II), diagnosed by cranial ultrasound, had long been considered rather not to affect neurodevelopmental and motor outcome, a view challenged by several literature reports. However, diversity in studies design, periods of subjects' collection, cohort characteristics, demographic data, maternal or neonatal comorbidities, neuroimaging methods, evaluation tools, short-or-long-term follow-up by the same or different examiners, as well as other parameters and confounders make comparisons among reports very difficult, not allowing solid conclusions. Older, but also newer investigations claim both possible outcomes: impairment or not of cognitive and motor abilities in very preterm infants with low-grade IVH. Thus, the current suggestion in the relevant literature is not to rely only on the results of cranial ultrasounds, but to also implement classic, or even more advanced MRI techniques at term equivalent age to preterm infants with grade I or II IVH. In addition, the continuation of close follow-up during school age is warranted.

Preterm brain injury: Germinal matrix-intraventricular hemorrhage and post-hemorrhagic ventricular dilatation

Germinal matrix hemorrhage and intraventricular hemorrhages (GMH-IVH) remain a common and clinically significant problem in preterm infants, particularly extremely preterm infants. A large GMH-IVH is often complicated by posthemorrhagic ventricular dilation (PHVD) or parenchymal hemorrhagic infarction and is associated with an increased risk of adverse neurologic sequelae. The widespread use of cranial ultrasonography since the early 1980s has shown a gradual decrease in the incidence of GMH-IVH and has helped with the identification of antenatal and perinatal risk factors and timing of the lesion. The increased use of magnetic resonance imaging (MRI) has contributed to more detailed visualization of the site and extent of the GMH-IVH. In addition, MRI has contributed to the awareness of associated white matter changes as well as associated cerebellar hemorrhages. Although GMH-IVH and PHVD still cannot be prevented, cerebrospinal fluid drainage initiated in the early stage of PHVD development seems to be associated with a better neurodevelopmental outcome. Further studies are underway to improve treatment strategies for PHVD and to potentially prevent and repair GMH-IVH and PHVD and associated brain injury. This chapter discusses the pathogenesis, incidence, risk factors, and management, including preventive measures, of GHM-IVH and PHVD.

Body Structure, Function, Activity, and Participation in 3- to 6-Year-Old Children Born Very Preterm: An ICF-Based Systematic Review and Meta-Analysis

BACKGROUND

The World Health Organization's International Classification of Functioning, Disability, and Health framework, Children and Youth Version (ICF-CY), provides a valuable method of conceptualizing the multidomain difficulties experienced by children born very preterm (VP). Reviews investigating motor outcomes at preschool age across ICF-CY domains are lacking.

PURPOSE

The purpose of this review is to identify and compare motor outcomes of 3- to 6-year-old children born VP and children born full-term (FT) within the ICF-CY framework.

DATA SOURCES

Four electronic databases and reference lists of included and key articles were searched.

STUDY SELECTION

Studies comparing motor outcomes of 3- to 6-year-old children born VP (<32 weeks' gestation or birth weight <1500 g) with peers born FT were included.

DATA EXTRACTION

Two independent authors extracted data and completed quality assessments.

DATA SYNTHESIS

Thirty-six studies were included. Activity motor performance of children born VP was consistently poorer compared with peers born FT: standardized mean difference (SMD) was -0.71 (95% CI = -0.80 to -0.61; 14 studies, 2056 participants). Furthermore, children born VP had higher relative risk (RR) of motor impairment (RR = 3.39; 95% CI = 2.68 to 4.27; 9 studies, 3466 participants). Body structure and function outcomes were largely unable to be pooled because assessment tools varied too widely. However, children born VP had higher RR of any neurological dysfunction (Touwen Neurological Examination) (RR = 4.55; 95% CI = 1.20 to 17.17; 3 studies, 1363 participants). There were no participation outcome data.

LIMITATIONS

Limitations include the lack of consistent assessment tools used in VP follow-up at preschool age and the quality of the evidence.

CONCLUSIONS

Children born VP experience significant motor impairment across ICF-CY activity and body structure and function domains at preschool age compared with peers born FT. Evidence investigating participation in VP preschool-age populations relative to children born at term is sparse, requiring further research.

The Impact of Low-Grade Germinal Matrix-Intraventricular Hemorrhage on Neurodevelopmental Outcome of Very Preterm Infants

BACKGROUND

Very preterm infants often show germinal matrix-intraventricular hemorrhage (GMH-IVH) on cranial ultrasound (cUS).

AIM

To determine the impact of low-grade GMH-IVH on early neurodevelopmental outcome in very preterm infants.

METHODS

A retrospective case-control study in very preterm infants with and without low-grade GMH-IVH on cUS. Additional magnetic resonance imaging (MRI) was available in all infants with a gestational age (GA) <28 weeks and high-risk infants >28 weeks. Infants were seen at 2 years' corrected age to assess neurodevelopment.

RESULTS

In total, 136 infants (GA 24-32 weeks) with low-grade GMH-IVH on cUS were matched with 255 controls. Outcome data was available for 342 (87%) infants. Adverse outcome (i.e., cerebral palsy [CP], neurodevelopmental delay) was present in 11 (9%) cases and 20 (9%) controls. No statistically significant differences in outcome were found between cases and controls. Additional MRI was performed in 165/391 infants (42%) and showed additional lesions in 73 (44%) infants that could explain subsequent development of CP in 2 out of 5 infants and epilepsy in 1 of 2 infants.

CONCLUSION

Very preterm infants with low-grade GMH-IVH on cUS have a similar early neurodevelopmental outcome compared with controls. Additional MRI showed mostly subtle abnormalities that were missed with cUS, but these could not explain subsequent development of CP and developmental delay in all infants.

The Impact of Low-risk Prematurity on Maternal Behaviour and Toddler Outcomes

This short-term longitudinal research project was designed to compare the maternal behaviour of mothers whose toddlers had been born preterm with the maternal behaviour of mothers whose toddlers had been born at term; the outcomes for the toddlers were also assessed. Twenty-one toddlers who had been born preterm with low medical risk (1460-2420 grams) were compared with 21 term toddlers who were matched in terms of social class. The heightened maternal responsiveness that had been observed during the first year with preterm infants had disappeared by 12 months, and by 20 months it was the mothers whose infants had been born at term who were more vocally responsive. During the second year, the mothers of preterm toddlers were characterised by more maternal control behaviour than were the mothers of term toddlers. Assessments of cognitive and language performance at the gestationally corrected ages of 12 and 20 months did not differentiate the toddlers who had been born preterm and term. In terms of play skills, reflected during interaction with their mothers at 12 and 20 months, the preterm toddlers were more actively involved than were the term toddlers. Despite the successful adjustment of these low-risk preterm toddlers, maternal behaviour was affected by the circumstances of preterm birth, even after 20 months.

Risk of ultrasound-detected neonatal brain abnormalities in intrauterine growth-restricted fetuses born between 28 and 34 weeks' gestation: relationship with gestational age at birth and fetal Doppler parameters

OBJECTIVE

To estimate the value of gestational age at birth and fetal Doppler parameters in predicting the risk of neonatal cranial abnormalities in intrauterine growth-restricted (IUGR) fetuses born between 28 and 34 weeks' gestation.

METHODS

Fetal Doppler parameters including umbilical artery (UA), middle cerebral artery (MCA), aortic isthmus, ductus venosus and myocardial performance index were evaluated in a cohort of 90 IUGR fetuses with abnormal UA Doppler delivered between 28 and 34 weeks' gestation and in 90 control fetuses matched for gestational age. The value of gestational age at birth and fetal Doppler parameters in predicting the risk of ultrasound-detected cranial abnormalities (CUA), including intraventricular hemorrhage, periventricular leukomalacia and basal ganglia lesions, was analyzed.

RESULTS

Overall, IUGR fetuses showed a significantly higher incidence of CUA than did control fetuses (40.0% vs 12.2%, respectively; P < 0.001). Within the IUGR group, all predictive variables were associated individually with the risk of CUA, but fetal Doppler parameters rather than gestational age at birth were identified as the best predictor. MCA Doppler distinguished two groups with different degrees of risk of CUA (48.5% vs 13.6%, respectively; P < 0.01). In the subgroup with MCA vasodilation, presence of aortic isthmus retrograde net blood flow, compared to antegrade flow, allowed identification of a subgroup of cases with the highest risk of CUA (66.7% vs 38.6%, respectively; P < 0.05).

CONCLUSION

Evaluation of fetal Doppler parameters, rather than gestational age at birth, allows identification of IUGR preterm fetuses at risk of neonatal brain abnormalities.

Outcomes of intraventricular hemorrhage and posthemorrhagic hydrocephalus in a population-based cohort of very preterm infants born to residents of Nova Scotia from 1993 to 2010

OBJECT Intraventicular hemorrhage (IVH) is a common complication of preterm birth, and the prognosis of IVH is incompletely characterized. The objective of this study was to describe the outcomes of IVH in a population-based cohort with minimal selection bias. METHODS All very preterm (≥ 30 completed weeks) patients born in the province of Nova Scotia were included in a comprehensive database. This database was screened for infants born to residents of Nova Scotia from January 1, 1993, to December 31, 2010. Among very preterm infants successfully resuscitated at birth, the numbers of infants who died, were disabled, developed cerebral palsy, developed hydrocephalus, were blind, were deaf, or had cognitive/language scores assessed were analyzed by IVH grade. The relative risk of each outcome was calculated (relative to the risk for infants without IVH). RESULTS Grades 2, 3, and 4 IVH were significantly associated with an increased overall mortality, primarily in the neonatal period, and the risk increased with increasing grade of IVH. Grade 4 IVH was significantly associated with an increased risk of disability (RR 2.00, p < 0.001), and the disability appeared to be primarily due to cerebral palsy (RR 6.07, p < 0.001) and cognitive impairment (difference in mean MDI scores between Grade 4 IVH and no IVH: -19.7, p < 0.001). No infants with Grade 1 or 2 IVH developed hydrocephalus, and hydrocephalus and CSF shunting were not associated with poorer outcomes when controlling for IVH grade. CONCLUSIONS Grades 1 and 2 IVH have much better outcomes than Grades 3 or 4, including a 0% risk of hydrocephalus in the Grade 1 and 2 IVH cohort. Given the low risk of selection bias, the results of this study may be helpful in discussing prognosis with families of very preterm infants diagnosed with IVH.

Predictors of neurodevelopmental outcomes in preterm infants with intraparenchymal hemorrhage

OBJECTIVE

To determine which neuroimaging, clinical and sociodemographic factors predict neurodevelopment at 18-22 months age among extremely preterm infants with intraparenchymal hemorrhage (IPH).

STUDY DESIGN

Cranial ultrasounds performed before 42 days of age and cranial ultrasounds/magnetic resonance images of the brain performed near discharge were reviewed for hemorrhage location and other abnormalities. Clinical and sociodemographic factors were extracted from existing databases. The primary outcome was presence of cerebral palsy (CP) and the secondary outcome was cognitive development (Bayley Scales of Infant Development).

RESULT

Of 1168 infants (<1000 g or <27 weeks), 141 infants had an IPH and 48 infants were seen in follow-up. All infants with extensive hemorrhages (involving three or more lobes) developed CP. In early imaging (before 42 days of age), ventriculomegaly, intraventricular hemorrhage (IVH) and extensive hemorrhage were predictors of CP. In imaging performed near discharge, ventriculomegaly, intraventricular echodensity and having a ventricular shunt were predictors of CP. Clinical, imaging and sociodemographic factors were not associated with low cognitive score.

CONCLUSION

In preterm infants surviving with IPH, extensive hemorrhage, ventriculomegaly, IVH and having a shunt increased the risk of developing CP.

A predictive model for SIVH risk in preterm infants and targeted indomethacin therapy for prevention

Prophylactic indomethacin may decrease Severe Intraventricular Hemorrhage (SIVH). Our goal was to develop a predictive model for SIVH using parameters available by six hours of age. De-identified data for preterm infants born ≤ 34 weeks gestational age was abstracted from Vermont Oxford Network database. Using clinical variables available by 6 hrs of age the model was developed, and validated. Statistical methods were used to evaluate the ability of the model to discriminate infants with and without SIVH and, to compare observed and predicted risk. The model achieved excellent discrimination as indicated by ROC curve of 0·85. A good agreement was noted between observed and predicted risk (HLtest: p = 0·22). Application of the model to patients receiving indomethacin suggests a benefit at the highest risk levels. We have developed a valid predictive model for predicting SIVH as well as shown that exposure to indomethacin decreases the incidence of SIVH overall.

Neurobehavioral development of preterm and full term children: biomedical and environmental influences

BACKGROUND

Previous studies indicate that VLBW preterm children obtain significantly lower scores than full-term children in all the NBAS clusters. However the samples studied usually presented additional medical complications.

AIMS

The present study aims to compare the results obtained by low-risk preterm and full term children in the NBAS, and relate possible differences to biological and contextual factors.

METHOD

Early neurobehavioral development of 150 preterm (PR) children is compared to that of 49 full term children (FT). The children were assessed at the age of 15 days (corrected age for preterm children) with the NBAS. Biological and environmental variables were collected through an extended interview with the mothers as well as medical data.

RESULTS

Significant differences were found between preterm and full term children in the following areas: motor, range of state, and regulation of state. Differences were also found in relation to birth weight in these same three areas, following a parallel pattern. These differences between the two groups were not, however, necessarily more favorable for the FT group; the PR group had higher results in the motor and range of state areas, and lower results in the regulation of state area. The mothers' smoking habit had a negative effect on infants' regulation and orientation.

CONCLUSIONS

No general maturation delay in this particular sample of preterm children was found.

Neurodevelopmental outcomes of extremely low-gestational-age neonates with low-grade periventricular-intraventricular hemorrhage

IMPORTANCE

Low-grade periventricular-intraventricular hemorrhage is a common neurologic morbidity among extremely low-gestational-age neonates, yet the outcomes associated with this morbidity are not fully understood. In a contemporary multicenter cohort, we evaluated the impact of such hemorrhages on early (18-22 month) neurodevelopmental outcomes of extremely premature infants.

OBJECTIVE

To compare neurodevelopmental outcomes at 18 to 22 months' corrected age for extremely low-gestational-age infants with low-grade (grade 1 or 2) periventricular-intraventricular hemorrhage with those of infants with either no hemorrhage or severe (grade 3 or 4) hemorrhage demonstrated on cranial ultrasonography.

DESIGN

Longitudinal observational study.

SETTING

Sixteen centers of the Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network.

PARTICIPANTS

A total of 1472 infants born at less than 27 weeks' gestational age between January 1, 2006, and December 31, 2008, with ultrasonography results within the first 28 days of life and surviving to 18 to 22 months with complete follow-up assessments were eligible.

MAIN EXPOSURE

Low-grade periventricular-intraventricular hemorrhage.

MAIN OUTCOME MEASURES

Outcomes included cerebral palsy; gross motor functional limitation; cognitive and language scores according to the Bayley Scales of Infant Development, 3rd Edition; and composite measures of neurodevelopmental impairment. Regression modeling evaluated the association of hemorrhage severity with adverse outcomes while controlling for potentially confounding variables and center differences.

RESULTS

Low-grade hemorrhage was not associated with significant differences in unadjusted or adjusted risk of any adverse neurodevelopmental outcome compared with infants without hemorrhage. Compared with low-grade hemorrhage, severe hemorrhage was associated with decreased adjusted continuous cognitive (β, -3.91 [95% CI, -6.41 to -1.42]) and language (β, -3.19 [-6.19 to -0.19]) scores as well as increased odds of each adjusted categorical outcome except severe cognitive impairment (odds ratio [OR], 1.46 [0.74 to 2.88]) and mild language impairment (OR, 1.35 [0.88 to 2.06]).

CONCLUSIONS AND RELEVANCE

At 18 to 22 months, the neurodevelopmental outcomes of extremely low-gestational-age infants with low-grade periventricular-intraventricular hemorrhage are not significantly different from those without hemorrhage. Additional study at school age and beyond would be informative.

Brain structure and executive functions in children with cerebral palsy: a systematic review

This systematic review aimed to establish the current knowledge about brain structure and executive function (EF) in children with cerebral palsy (CP). Five databases were searched (up till July 2012). Six articles met the inclusion criteria, all included structural brain imaging though no functional brain imaging. Study quality was assessed using the STROBE checklist. All articles scored between 58.7% and 70.5% for quality (100% is the maximum score). The included studies all reported poorer performance on EF tasks for children with CP compared to children without CP. For the selected EF measures non-significant effect sizes were found for the CP group compared to a semi-control group (children without cognitive deficits but not included in a control group). This could be due to the small sample sizes, group heterogeneity and lack of comparison of the CP group to typically developing children. The included studies did not consider specific brain areas associated with EF performance. To conclude, there is a paucity of brain imaging studies focused on EF in children with CP, especially of studies that include functional brain imaging. Outcomes of the present studies are difficult to compare as each study included different EF measures and cortical abnormality measures.

Perinatal Outcomes in Preterm Growth-Restricted Twins: Effects of Gestational Age and Fetal Condition

Objective: To evaluate the perinatal outcome of intrauterine growth-restricted preterm twins and contribution of prematurity to morbidity and mortality. Study design: A case–control study of 211 preterm twins: 108 growth-restricted twins matched with 103 normal growth twins of the same gestational age. Mortality and morbidity rates were compared between groups. Result: Fetal and overall perinatal mortality rates of growth-restricted fetuses were higher than normal growth ones. Respiratory distress syndrome incidence was lower and neurologic sequelae incidence higher in growth-restricted twins. No differences were observed between groups with respect to neonatal mortality, low Apgar score, neonatal intensive care unit admission, periventricular hemorrhage, sepsis, jaundice, and hematologic or metabolic disorders. Conclusion: Adverse perinatal outcomes of preterm twins complicated with intrauterine growth restriction are represented by a higher antepartum mortality rate, but once born alive, neonatal outcomes seem to be associated only with gestational age at birth, excluding a protective effect on lung maturation and a higher risk of long-term neurologic sequelae.

The impact of ethnic population dynamics on neonatal ECMO outcomes: a single urban institutional study

INTRODUCTION

Neonatal extracorporeal membrane oxygenation ECMO has been clinically used for the last 25 y. It has been an effective tool for both cardiac and non cardiac conditions. The impact of ethno-demographic changes on ECMO outcomes however remains unknown. We evaluated a single institution's experience with non cardiac neonatal ECMO over a 28-y period.

METHODS

A retrospective review of all neonates undergoing noncardiac ECMO between the y 1984 and 2011 was conducted and stratified into year groups I, II, III (≤1990, 1991-2000, and ≥2001). Demographic, clinical, and outcome data were collected. The patient specifics, ECMO type, ECMO length, blood use, complications, and outcomes were analyzed. Univariate, bivariate, and multivariate analyses were then performed.

RESULTS

Data was available for 827 patients. The number of African-American and Hispanic patients increased over the last 27 y (27.5% versus 45.0% and 3.3% versus 21.5%, year group I versus year group III, respectively). The proportion of congenital diaphragmatic hernia (CDH) patients by ethnicity also increased for African-Americans and Hispanics between the two year groups (22.0% to 33.0% and 4.9% to 33.0%, respectively). Similar pattern was noted for non-CDH diagnoses. Low birth weight, low APGAR scores, CDH, primary pulmonary hypertension, central nervous system hemorrhage, and ECMO were independent predictors of mortality. Ethnicity, in itself however, was not associated with mortality on adjusted analysis.

CONCLUSION

More African-Americans and Hispanics have required ECMO over the years with a concurrent decrease in the number of Caucasians. While ethnicity was not an independent predictor of mortality, it appears to be a surrogate for fatal but sometime preventable diagnoses among minorities. Further investigations are needed to better delineate the reason behind this disparity.

Consequences of intraventricular hemorrhage in a rabbit pup model

BACKGROUND AND PURPOSE

Intraventricular hemorrhage (IVH) is a common complication of prematurity that results in neurological sequelae, including cerebral palsy, posthemorrhagic hydrocephalus, and cognitive deficits. Despite this, there is no standardized animal model exhibiting neurological consequences of IVH in prematurely delivered animals. We asked whether induction of moderate-to-severe IVH in premature rabbit pups would produce long-term sequelae of cerebral palsy, posthemorrhagic hydrocephalus, reduced myelination, and gliosis.

METHODS

The premature rabbit pups, delivered by cesarean section, were treated with intraperitoneal glycerol at 2 hours postnatal age to induce IVH. The development of IVH was diagnosed by head ultrasound at 24 hours of age. Neurobehavioral, histological, and ultrastructural evaluation and diffusion tensor imaging studies were performed at 2 weeks of age.

RESULTS

Although 25% of pups with IVH (IVH pups) developed motor impairment with hypertonia and 42% developed posthemorrhagic ventriculomegaly, pups without IVH (non-IVH) were unremarkable. Immunolabeling revealed reduced myelination in the white matter of IVH pups compared with saline- and glycerol-treated non-IVH controls. Reduced myelination was confirmed by Western blot analysis. There was evidence of gliosis in IVH pups. Ultrastructural studies in IVH pups showed that myelinated and unmyelinated fibers were relatively preserved except for focal axonal injury. Diffusion tensor imaging showed reduction in fractional anisotropy and white matter volume confirming white matter injury in IVH pups.

CONCLUSION

The rabbit pups with IVH displayed posthemorrhagic ventriculomegaly, gliosis, reduced myelination, and motor deficits, like humans. The study highlights an instructive animal model of the neurological consequences of IVH, which can be used to evaluate strategies in the prevention and treatment of posthemorrhagic complications.

The diagnosis, management, and postnatal prevention of intraventricular hemorrhage in the preterm neonate

Intraventricular hemorrhage (IVH) occurs in 20% to 25% of very low birthweight preterm neonates and may be associated with significant sequelae. Infants who have IVH are at risk for posthemorrhagic hydrocephalus and periventricular leukomalacia; as many as 75% of those who have parenchymal involvement of hemorrhage suffer significant neurodevelopmental disability. Because of the prevalence of IVH and the medical and societal impact of this disease, many postnatal pharmacologic prevention strategies have been explored. Randomized clinical prevention trials should provide long-term neurodevelopmental follow-up to assess the impact of preterm birth, injury, and pharmacologic intervention on the developing brain.

General background on the hypothalamic-pituitary-thyroid (HPT) axis

This article reviews the thyroid system, mainly from a mammalian standpoint. However, the thyroid system is highly conserved among vertebrate species, so the general information on thyroid hormone production and feedback through the hypothalamic-pituitary-thyroid (HPT) axis should be considered for all vertebrates, while species-specific differences are highlighted in the individual articles. This background article begins by outlining the HPT axis with its components and functions. For example, it describes the thyroid gland, its structure and development, how thyroid hormones are synthesized and regulated, the role of iodine in thyroid hormone synthesis, and finally how the thyroid hormones are released from the thyroid gland. It then progresses to detail areas within the thyroid system where disruption could occur or is already known to occur. It describes how thyroid hormone is transported in the serum and into the tissues on a cellular level, and how thyroid hormone is metabolized. There is an in-depth description of the alpha and beta thyroid hormone receptors and their functions, including how they are regulated, and what has been learned from the receptor knockout mouse models. The nongenomic actions of thyroid hormone are also described, such as in glucose uptake, mitochondrial effects, and its role in actin polymerization and vesicular recycling. The article discusses the concept of compensation within the HPT axis and how this fits into the paradigms that exist in thyroid toxicology/endocrinology. There is a section on thyroid hormone and its role in mammalian development: specifically, how it affects brain development when there is disruption to the maternal, the fetal, the newborn (congenital), or the infant thyroid system. Thyroid function during pregnancy is critical to normal development of the fetus, and several spontaneous mutant mouse lines are described that provide research tools to understand the mechanisms of thyroid hormone during mammalian brain development. Overall this article provides a basic understanding of the thyroid system and its components. The complexity of the thyroid system is clearly demonstrated, as are new areas of research on thyroid hormone physiology and thyroid hormone action developing within the field of thyroid endocrinology. This review provides the background necessary to review the current assays and endpoints described in the following articles for rodents, fishes, amphibians, and birds.

The Impact of Periventricular Brain Injury on Reading and Spelling Abilities in the Late Elementary and Adolescent Years

The present study was designed: (1) to investigate the long-term consequences of both the presence and the severity of periventricular brain injury (PVBI) on intellectual, academic, and cognitive outcome in extremely-low-birthweight (ELBW: < 1,000 grams) children at a mean age of 11 years; and (2) to determine the nature of the underlying difficulties associated with academic problems in these children. The results indicated that ELBW children without PVBI performed as well as full-term children on intelligence, academic, and cognitive ability tests. In contrast, ELBW children with mild and severe PVBI achieved significantly lower scores than either ELBW children without PVBI or children who were born at term. A second analysis indicated that, after accounting for Full Scale IQ, working memory and phonological processing were significant predictors of reading and spelling performance in ELBW children. These findings suggest that the presence and severity of PVBI, and not ELBW status alone, is associated with performance on tests of intelligence, and academic and cognitive functioning, and that some of the same factors known to be associated with learning disabilities in full-term children contribute to learning disabilities in ELBW children.

Indomethacin prophylaxis for preterm infants: the impact of 2 multicentered randomized controlled trials on clinical practice

OBJECTIVES

Two multicenter randomized controlled trials (RCTs) in premature infants (Ment et al, 1994 and TIPP, 2001) found beneficial effects of indomethacin prophylaxis on the incidences of patent ductus arteriosus (PDA), PDA ligation, and severe intracranial hemorrhage (ICH). The Ment trial recommended the use of indomethacin prophylaxis. The TIPP trial failed to find a benefit in its primary outcome (improved survival/neurodevelopmental outcome); this negative result may have discouraged indomethacin prophylaxis use.

STUDY DESIGN

We used the National Institute of Child Health and Development's Neonatal Network Registry to determine the association between the 2 trials and the use of indomethacin prophylaxis. We also statistically assessed the assumptions that led to the TIPP trial's negative results.

RESULTS

Use of indomethacin prophylaxis among network clinicians increased after publication of the Ment trial and decreased after the TIPP trial. Analysis of the TIPP trial showed that the primary outcome's anticipated effect size (> or = 20%) was too large; a smaller effect size (< 3%) would have been more appropriate based on the incidence of ICH in their population and its association with neurodevelopmental outcome.

CONCLUSIONS

Two multicenter RCTs were associated with changes in indomethacin prophylaxis. After the Ment trial, the use of indomethacin prophylaxis increased. After the TIPP trial, which reported negative results based on an excessively large anticipated effect size, its use decreased.

Alterations in neurobehavior at term reflect differing perinatal exposures in very preterm infants

OBJECTIVES

Preterm infants have higher rates of cognitive and behavioral difficulties at school age than their term-born peers. We hypothesized that neurobehavior at term would be different in very preterm infants compared with term infants and that perinatal exposures would be associated with these alterations in neurobehavior.

PATIENTS AND METHODS

Two standardized neurobehavioral evaluations were completed on 207 infants at term equivalent, including 168 very preterm infants (<1250 g or <30 weeks' gestation) and 39 term control infants. The assessments used were the Neonatal Intensive Care Unit Network Neurobehavioral Scale and the revised Hammersmith Neonatal Neurologic Examination. The relationship of perinatal variables to preterm infant neurobehavioral scores for both evaluations was examined.

RESULTS

Compared with term-born infants, preterm infant neurobehavior was significantly altered for the Hammersmith Neonatal Neurologic Examination total score and all of the subtotals. Similarly, preterm infants displayed altered neurobehavior for the majority of the Neonatal Intensive Care Unit Network Neurobehavioral Scale summary scores. Complete perinatal data were available for 157 of 168 very preterm infants. The perinatal variables most strongly associated with altered preterm infant neurobehavior on multivariate regression analysis included the total number of days of assisted ventilation, intraventricular hemorrhage, and necrotizing enterocolitis. Positive perinatal influences on neurobehavioral performance at term on multivariate analysis included maternal antenatal steroids, female gender, and infants receiving breast milk at discharge home.

CONCLUSIONS

Preterm infants at term equivalent showed alterations in motor behavior and higher cortically integrated functions. The pattern of abnormality in neurobehavior differed in relation to perinatal exposures. Neurobehavioral examination at term equivalent age is useful in evaluating the impact of neonatal intensive care.

Predictive value of amplitude-integrated electroencephalography pattern and voltage in asphyxiated term infants

The aim of this study was to correlate amplitude-integrated electroencephalography soon after birth with neurodevelopmental outcome in children who suffered from hypoxic-ischemic encephalopathy. Near term infants with hypoxic-ischemic encephalopathy and amplitude-integrated electroencephalography recording before 6 hours of age were included. Neurologic and cognitive outcome were assessed at 30 months of age and over. Outcome was correlated with either the pattern or voltage of the tracing. Thirty-nine infants were included. Eight died in the immediate neonatal period. At the age of 3 and 6 hours, sensitivity of low voltage to poor outcome was 33% and 42% respectively and of burst suppression pattern to poor outcome was 83% and 75% respectively. Association of voltage to outcome was significant only at 6 hours of age (P = 0.025). Association of pattern to outcome was significant both at 3 and 6 hours of age (P = 0.003, 0.008). These data on amplitude-integrated electroencephalography predictive value early in life were similar to previous studies. Burst suppression pattern, as early as 3 hours of age, is associated with poor outcome. At the age of 6 hours, both low voltage and burst suppression are associated with poor outcome. Pattern seems more sensitive than voltage.

Impact of prenatal and/or postnatal growth problems in low birth weight preterm infants on school-age outcomes: an 8-year longitudinal evaluation

OBJECTIVE

The objective of this study was to assess the 8-year growth, cognitive, behavioral status, health status, and academic achievement in low birth weight preterm infants who had failure to thrive only, were small for gestational age only, had failure to thrive plus were small for gestational age, or had normal growth.

METHODS

A total of 985 infants received standardized evaluations to age 8; 180 infants met the criteria for failure to thrive between 4 and 36 months' gestational corrected age. The following outcome variables were collected at age 8: growth, cognitive, behavioral status, health status, and academic achievement. Multivariate analyses were performed among the 4 growth groups on all 8-year outcome variables.

RESULTS

Children who both were small for gestational age and had failure to thrive were the smallest in all growth variables at age 8, and they also demonstrated the lowest cognitive and academic achievement scores. The children with failure to thrive only were significantly smaller than the children with normal growth in all growth variables and had significantly lower IQ scores. Those who were small for gestational age only did not differ from those with normal growth in any cognitive or academic achievement measures. There were no differences among the 4 groups in behavioral status or general health status.

CONCLUSION

Low birth weight preterm infants who develop postnatal growth problems, particularly when associated with prenatal growth problems, demonstrate lower physical size, cognitive scores, and academic achievement at age 8. There does not seem to be an independent affect of small for gestational age status on 8-year cognitive status and academic achievement when postnatal growth is adequate.

Neurodevelopmental sequelae of intraventricular haemorrhage at 8 years of age in a regional cohort of ELBW/very preterm infants

BACKGROUND

Major grades of intraventricular haemorrhage (IVH) are associated with adverse neurodevelopmental sequelae in early childhood but the extent of problems in specific cognitive areas, such as executive function, and the contribution of lesser grades of IVH to neurodevelopmental problems at school age are not well described.

AIMS

To determine the neuromotor, cognitive and educational outcome of extremely low birthweight (ELBW, birthweight <1000 g) or very preterm (<28 weeks) infants at 8 years of age related to the severity of IVH diagnosed in the newborn period.

DESIGN

Regional cohort study.

PATIENTS

Consecutive surviving children of either birthweight <1000 g or gestational age <28 weeks born in the state of Victoria in 1991 or 1992.

MAIN OUTCOME MEASURES

Neurological impairments and disabilities, cognitive function and academic progress.

RESULTS

Of 298 consecutive ELBW/very preterm survivors 270 (90.6%) with cranial ultrasound data were assessed at 8 years of age. Cerebral palsy, poor motor performance and major neurosensory disability were more prevalent with increasing severity of IVH. Cognitive functioning across domains was worse with increasing severity of IVH. Most of the differences were attributable to the few (n=6) survivors who had grade 4 IVH; there were few substantial differences between survivors with lesser grades of IVH.

CONCLUSIONS

Neurodevelopmental dysfunction at school age in ELBW/very preterm survivors varies little with increasing severity of IVH, with the exception of grade 4 IVH.

Development and behavior of non-handicapped preterm children from a developing country

BACKGROUND

There are many studies, mainly conducted in industrialized countries, concerning developmental and behavioral outcomes of preterm children. However, little is known about the outcomes of preterm children from developing countries.

METHOD

Forty-three non-handicapped Turkish preterm children, 15 with very low birth weight and 28 with low birth weight at preschool age, as well as 36 term controls were compared on rates of developmental, emotional and behavioral impairments. Data were collected by review of hospital records and application of various questionnaires and inventories to both children and their parents.

RESULTS

Preterm children had significant delays in general development and significant rise in somatic complaints with unknown medical etiologies. The very low birth weight group also had significant delay in language and cognitive development. Parents of the preterm children displayed significantly higher rates of democratic attitudes. Developmental outcome was significantly associated with birth weight and authoritarian parental attitudes where behavioral outcome was significantly influenced by birth weight.

CONCLUSION

Presence of developmental delay is in accordance with existing data on the outcomes of preterm children from industrialized countries. An isolated increase in somatic complaints is an uncommon finding which might also be related to cultural factors.

Psychosocial and academic characteristics of extremely low birth weight (< or =800 g) adolescents who are free of major impairment compared with term-born control subjects

OBJECTIVE

To compare academic and cognitive ability, attention, attitudes, and behavior of extremely low birth weight (ELBW) adolescents who are free of major impairments at 17 years of age with term-born control subjects.

METHODS

Between January 31, 1981, and February 9, 1986, 250 infants of < or =800 g were admitted for intensive care in British Columbia, 98 (39%) of whom survived to late adolescence. Teens with major sensorimotor handicaps and/or IQ <70 were excluded (n = 19). Of the 79 eligible ELBW teens, 53 (67%) were assessed at 17.3 (16.3-19.7) years (birth weight: 720 [520-800 g]; gestation: 26 [23-29] weeks). The test battery screened the following areas: cognitive (Wechsler Intelligence Scale for Adults Third Edition, 3 subtests), academic (Wide Range Achievement Test-3), attention (Connors' Continuous Performance Task), self-report (Harter Self-Perception Profile for Adolescents; Job Search Attitude Inventory), and parent report (Child Behavior Check List). A comparison group of term born control subjects (n = 31) were also assessed (birth weight: 3506 [3068-4196] g; gestation: 40 [39-42] weeks) at age 17.8 (16.5-19.0) years. Multivariate analysis of variance (group x gender) was conducted for each domain (cognitive, academic, self-report, and parent report).

RESULTS

The ELBW group showed lower cognitive scores (vocabulary, block design, and digit symbol) and academic skills (reading and arithmetic) compared with control subjects, with no gender differences. There were no differences in attention between the 2 groups using a repetitive computer task. ELBW teens reported lower scholastic, athletic, job competence, and romantic confidence and viewed themselves as more likely to need help from others in finding a job. In the behavioral domain, parents reported their ELBW teens to display more internalizing, more externalizing, and more total problems than the control teens, with ELBW boys showing more problems. ELBW teens showed a higher percentage of clinically significant behavior problems than control subjects.

CONCLUSIONS

In a provincial cohort of unimpaired survivors of birth weight < or =800 g, psychosocial and educational vulnerabilities persist into late adolescence and may complicate the transition to adult life compared with their peers.

Preterm birth: a cost benefit analysis

Advances in prenatal and perinatal treatment of preterm and VLBW infants have dramatically increased the survival rate of these infants. Some interventions decrease long term sequelae associated with preterm birth, making them more cost-effective than other treatments. This paper reviews the cost-effectiveness of therapies targeted to protect the preterm brain. Birth in a center with a NICU improves survival and decreases the rate of severe neurologic disability. Administration of antenatal steroids increases survival and decreases rates of periventricular hemorrhage, periventricular leukomalacia, necrotizing enterocolitis, respiratory distress syndrome, and severe disability. Administration of antenatal steroids decreases costs per additional survivor. Addition of surfactant to the treatment of PT infants has also decreased treatment costs. Administration of surfactant is beneficial for symptomatic RDS but recognizes a greater benefit when given to infants younger than 30 weeks gestation prophylactically. Treatment with prophylactic indomethacin decreases the rate of intraventricular hemorrhage and results in cost savings in survivors. Postnatal administration of dexamethasone can lead to severe disability when administered before 7 to 10 days of life. Postnatal dexamethasone does not increase survival or decrease rates of chronic lung disease.

Uncomplicated intraventricular hemorrhage is followed by reduced cortical volume at near-term age

BACKGROUND

Intraventricular hemorrhage (IVH) is the most common brain injury among premature infants. Neonates with IVH are at greater risk of impaired neurodevelopmental outcomes, compared with those without IVH. IVH causes destruction of the germinal matrix and glial precursor cells, with possible effects on cortical development.

OBJECTIVE

To investigate cortical development after uncomplicated IVH (with no parenchymal involvement and no posthemorrhagic hydrocephalus). We hypothesized that uncomplicated IVH would be followed by reduced cortical volume among premature infants at near-term age.

METHODS

A prospective cohort study was conducted, with preset selection criteria. Infants with small-for-gestational age birth weight, congenital abnormalities or brain malformations, metabolic disorders, recurrent sepsis, or necrotizing enterocolitis were excluded. Also, infants with posthemorrhagic hydrocephalus, parenchymal involvement of hemorrhage, cystic periventricular leukomalacia, or persistent ventriculomegaly were excluded, on the basis of routine serial ultrasonographic assessments. Three-dimensional images were acquired for 23 infants at near-term age, with 3-T magnetic resonance imaging and a magnetization-prepared rapid gradient echo sequence. Image analysis and segmentation of the cerebrum in different tissue types were based on signal contrast and anatomic localization. The cortical gray matter (CGM), subcortical gray matter, white matter, and intraventricular cerebrospinal fluid volumes of 12 infants with uncomplicated IVH were compared with those of 11 infants without IVH, using multivariate analysis of variance.

RESULTS

The multivariate analysis of variance for the regional brain volumes in the 2 groups indicated significance (Wilks' lambda = 0.546). The CGM volume was significantly reduced in the IVH group (no-IVH group: 122 +/- 12.9 mL; IVH group: 102 +/- 14.6 mL; F = 13.218). This finding remained significant after testing for possible confounding factors and adjustment for size differences between the infants (F = 9.415). There was no difference in the volumes of subcortical gray matter, white matter, and cerebrospinal fluid.

CONCLUSIONS

This is the first study to document impaired cortical development after uncomplicated IVH. The impairment was demonstrated by a 16% reduction in cerebral CGM volume at near-term age. The finding supports concerns regarding possible glial precursor cell loss after germinal matrix IVH, but its clinical significance is still unclear. The alteration in brain development demonstrated in this report supports closer neurodevelopmental follow-up monitoring of preterm infants with uncomplicated IVH.

Atypical auditory event-related potentials in preterm infants during the first year of life: a possible sign of cognitive dysfunction?

We assessed auditory event-related potentials in small-for-gestational-age (SGA; 850 +/- 258 g, 28.9 +/- 3.3 gestational wk; n = 15) and appropriate for gestational age (AGA; 1014 +/- 231 g, 26.9 +/- 1.9 gestational wk; n = 20) preterm infants and healthy term infants (n = 22). An oddball paradigm was used with a harmonic tone of 500-Hz frequency as the standard and of 750-Hz frequency as the deviant stimulus. The preterm infants were studied at 40 gestational wk and at 6 and 12 mo of corrected age, and the control subjects were studied at 2-4 d and at 3, 6, 9, 12, and 15 mo of age. The peaks of interest were the main positive peak (P350), the negative peaks at 250 ms (N250) and 650 ms (Nc), and the mismatch negativity at 200 ms (MMN). At term, the P350 in the preterm infants was similar to that of the newborn control subjects. In response to the deviant, the Nc was smaller in the SGA than in the AGA (P < 0.02) and control (P < 0.005) infants. The N250 amplitude was also lower in the SGA infants. At 12 mo, the MMN was observed in the control but not in the preterm infants, whose broad difference positivity correlated with the Bayley developmental index. The decreased Nc and N250 peaks in the SGA infants may suggest an increased risk for cognitive dysfunction. The broad difference positivity at 1 y of age may indicate atypical cortical auditory processing. Whether cognitive dysfunction can be predicted by these findings needs to be assessed in a study with extended follow-up.

Proactive management promotes outcome in extremely preterm infants: a population-based comparison of two perinatal management strategies

OBJECTIVE

There is a need for evidence-based knowledge regarding perinatal management in extreme prematurity. The benefit of a proactive attitude versus a more selective one is controversial. The objective of the present study was to analyze perinatal practices and infant outcome in extreme prematurity in relation to different management policies in the North (proactive) and South of Sweden.

METHODS

A population-based, retrospective, cohort study design was used. Data in the Swedish Medical Birth Register (MBR) from 1985 to 1999 were analyzed according to region of birth and gestational age (22 weeks + 0 days to 27 weeks + 6 days). A total of 3 602 live-born infants were included (North = 1040, South = 2562). Survival was defined as being alive at 1 year. Morbidity in survivors, based on discharge diagnoses of major morbidity during the first year of life, was described by linking the MBR to the Hospital Discharge Register.

RESULTS

In infants with a gestational age of 22 to 25 weeks, the proactive policy was significantly associated with 1) increased incidence of live births, 2) higher degree of centralized management, 3) higher frequency of caesarean section, 4) fewer infants with low Apgar score (<4) at 1 and 5 minutes, 5) fewer infants dead within 24 hours, and 6) increased number of infants alive at 1 year. There were no indications of increased morbidity in survivors of the proactive management during the first year of life, and the proportion of survivors without denoted morbidity was larger.

CONCLUSION

In infants with a gestational age of 22 to 25 weeks, a proactive perinatal strategy increases the number of live births and improves the infant's postnatal condition and survival without evidence of increasing morbidity in survivors up to 1 year of age.

Outcome of very low birth weight infants with sonographic enlarged occipital horn

The objective of this study is to compare the neurodevelopmental outcome between very low birth weight infants with and without sonographic disproportionate enlargement of occipital horn. We retrospectively reviewed the brain sonography of all very low birth weight infants born at National Taiwan University Hospital between June 1997 and June 1999. Brain sonography was routinely performed at the age of the third, seventh, twenty-first, and later days as clinically indicated. Intracranial hemorrhage, periventricular leukomalacia, congenital hydrocephalus, and Stage III retinopathy of prematurity were excluded from our study because of the association with neurodevelopmental impairment. Patients with disproportional dilatation of occipital horn more than 15 mm in width were included in the study group, and those with less than 15 mm were in the control group. Both groups received developmental evaluation by the Bayley Scales of Infant Development II at corrected age of 6, 12, 18, and 24 months, respectively. Socioeconomic status and detailed medical history were obtained at assessments. Independent-samples t test was used for comparison. A total of 81 very low birth weight infants were included in this study: 49 infants (female 18, male 31) in the study group and 32 infants (female 23, male 9) in the control group. The mean gestation in these two groups was 30 +/- 2 weeks and 31.1 +/- 2.2 weeks (P = 0.156), and the mean birth body weight was 1290 +/- 269 gm and 1282 +/- 219 gm (P = 0.877), respectively. At corrected age of 24 months, there was no significant difference in muscle tone, neuromotor impairment, hearing impairment, vision, or speech development. Assessment with the mental development index (88.9 +/- 15.6 vs 93 +/- 13.2) (P = 0.238) and the psychomotor development index (93.3 +/- 10.3 vs 89.6 +/- 12.1) (P = 0.149) between these two groups was also comparable. This retrospective analysis suggests that ultrasonographic disproportionate enlargement of the occipital horn in very low birth weight infants does not affect the neuromotor development at corrected ages of 6, 12, 18, and 24 months.

Does labor influence neonatal and neurodevelopmental outcomes of extremely-low-birth-weight infants who are born by cesarean delivery?

OBJECTIVE

The purpose of this study was to examine the influence of labor on extremely-low-birth-weight infants who were born by cesarean delivery with reference to neonatal and neurodevelopmental outcomes. We hypothesized that infants who are born by cesarean delivery without labor will have better outcomes than those infants who are born by cesarean delivery with labor.

STUDY DESIGN

This was a retrospective cohort study of extremely-low-birth-weight infants (birth weight, 401-1000 g) who were born by cesarean delivery and cared for in the National Institute for Child Health and Human Development Neonatal Network, during calendar years 1995 to 1997. A total of 1606 extremely-low-birth-weight infants were born by cesarean delivery and survived to discharge. Of these, 1273 infants (80.8%) were examined in the network follow-up clinics at 18 to 22 months of corrected age and had a complete data set (667 infants were born without labor, 606 infants were born with labor). Outcome variables that were examined include intraventricular hemorrhage grade 3 to 4, periventricular leukomalacia, and neurodevelopmental impairment.

RESULTS

Mothers in the cesarean delivery without labor group were older (P<.001), more likely to be married (P<.05), less likely to be supported by Medicaid (P<.01), more likely to have preeclampsia/hypertension (P<.001), more likely to receive prenatal steroids (P<.005), and less likely to have received antibiotics (P<.001). Infants who were born by cesarean delivery without labor had higher gestational age (P<.001), lower birth weight (P<.01), and were less likely to be outborn (P<.001). By univariate analysis, infants who were born by cesarean delivery with labor had a higher incidence of grade 3 to 4 intraventricular hemorrhage (23.3% vs 12.1%, P<.001), periventricular leukomalacia (8.5% vs 4.7%, P<.02), and neurodevelopmental impairment (41.7% vs 34.6%, P<.02). Logistic regression analysis that controlled for all maternal and neonatal demographic and clinical variables that were statistically associated with labor or no labor revealed that the significant differences in grade 3 to 4 intraventricular hemorrhage, periventricular leukomalacia, and neurodevelopmental impairment were no longer evident.

CONCLUSION

In extremely-low-birth-weight infants who were born by cesarean delivery and after control for other risk factors, labor does not appear to play a significant role in adverse neonatal outcomes and neurodevelopmental impairment at 18 to 22 months of corrected age.

Magnetic resonance imaging of preterm brain injury

Magnetic resonance imaging (MRI) has proved to be a valuable tool for monitoring development and pathology in the preterm brain. This imaging modality is useful for assessing numerous pathologies including periventricular leukomalacia, intraventricular haemorrhage/germinal layer haemorrhage, and periventricular haemorrhagic infarction, and can help to predict outcome in these infants. MRI has also allowed the detection of posterior fossa lesions, which are not easily seen with ultrasound. Additionally, and perhaps most relevant, quantitative MR studies have shown differences between the normal appearing preterm brain at term equivalent age and term born infants, confirming that the brain develops differently in the ex utero environment. Further studies using quantifiable MR techniques will improve our understanding of the effects of the ex utero environment, including aspects of neonatal intensive care on the developing brain.

Pregnancy outcomes associated with intrauterine growth restriction

OBJECTIVE

This study was undertaken to examine the incidence of intrauterine growth restriction (IUGR) and neonatal outcomes of pregnancies delivered from 26 to 41 weeks' gestation.

STUDY DESIGN

A retrospective review of a linked database of all deliveries in California in 1994 through 1996 that were reported to the Office of Statewide Health and Planning Development.

MATERIAL AND METHODS

A database of maternal and neonatal discharge summaries linked to birth and death certificates were examined for gestational age at delivery, diagnosis of IUGR, respiratory distress syndrome (RDS), intraventricular hemorrhage (IVH), necrotizing enterocolitis (NEC), length of stay, and hospital charges (CHA). More than 1.4 million singleton deliveries were examined by week of gestation and separated into the presence or absence of IUGR and then examined for adverse neonatal outcomes.

RESULTS

The frequency of IUGR was increased in the preterm newborn infants compared with those at 40 weeks' gestation (26 = 8.9%, 27 = 7.7%, 28 = 9.8%, 29 = 10.5%, 30 = 12.3%, 31 = 9.1%, 32 = 7.5%, 33 = 6.6%, 34 = 5.6%, 35 = 5.0%, 36 = 4.4%, 37 = 3.7%, 38 = 2.3%, 39 = 1.5%, 40 = 1.1%). Up to 28 weeks' gestation, the incidence of RDS was higher for infants without IUGR compared with infants with IUGR (not significant). Starting at 29 weeks' gestation, RDS was higher for infants with IUGR. Initially not significant, this difference was statistically significant starting from 34 weeks. The findings were similar for IVH, NEC, and length of stay. The threshold at which the relationship between the presence of IUGR and the outcome flipped was 30, 28, and 29 weeks, whereas significance was observed at 34, 35, and 30 weeks, respectively. CHA were always higher for those patients with IUGR but became significantly higher after 29 weeks.

CONCLUSION

IUGR was increased with prematurity and may represent an important risk factor to check for in women who present with preterm labor. Prematurity associated with adverse neonatal outcomes (RDS, IVH, NEC, CHA) were largely unaffected by IUGR until the third trimester. From then on, all adverse outcomes were increased compared with normally grown premature infants, suggesting a need for closer surveillance for IUGR in the third trimester.

Serial head ultrasound studies in preterm infants: how many normal studies does one infant need to exclude significant abnormalities?

OBJECTIVE

We hypothesized that preterm infants with two normal head ultrasound (HUS) screening studies > or = 7 days apart would have subsequently normal follow-up studies.

POPULATION

We reviewed reports of all HUS studies performed in preterm infants < or = 32 weeks gestation admitted to our nursery between January 1998 and July 2000.

SETTING

Regional perinatal referral center.

DESIGN

A normal HUS screening study was defined as either no findings; or grade I intraventricular hemorrhage (IVH) (Papile classification), germinal matrix irregularity or cyst, or normal but unequal ventricular size. An abnormal study was defined as any with IVH > or = grade II, periventricular leukomalacia (PVL), ventriculomegaly (VM), or periventricular echogenicity (PVE).

RESULTS

Of 98 infants, 92 infants (94%) who had two normal HUS studies > or = 7 days apart had normal repeat studies subsequently, and six (6%) were abnormal. Four of the six abnormal infants were <25 weeks gestation at birth. One infant (27 weeks) became abnormal after culture-positive bacterial sepsis and necrotizing enterocolitis with bowel perforation requiring surgery. The remaining infant (29 weeks) had a question of PVE, and a normal repeat study. The positive predictive value for having a normal HUS after two previously normal studies > or = 7 days apart was 94% with a specificity of 86%.

CONCLUSION

Stable premature infants > or = 25 weeks gestation without intervening deterioration may not need repeat screening HUSs after having had two normal studies > or = 7 days apart. Unstable or extremely premature infants <25 weeks gestation may be subject to late severe IVH, VM, and PVL, and therefore need a repeat study before hospital discharge, even if two initial studies > or = 7 days apart were normal.

Preschool development of very low birth weight children born 1994-1995

This study reports on the developmental outcome of a sample of pre-term children with a birth weight < or =1500 g born in 1994 and 1995 studied at the age of 5 to 6 years. The sample included 60 out of 81 surviving pre-term children (74.1%) of a German neonatal intensive care unit which was matched to a control group of 60 kindergarten children of the same region. The results show significant differences between term and pre-term children with regard to their intellectual development, language comprehension, attentiveness, and hyperactivity. Moreover, the pre-term children required more early intervention to compensate for developmental problems. The developmental deficits were intensified by the presence of biological risk factors like increasingly low birth weight, bronchopulmonary dysplasia and intraventricular haemorrhage.

CONCLUSION

differences between term and pre-term children still exist, although the early 1990s witnessed fundamental changes in the treatment of pre-term children. The persistence of these differences is explained mainly by the increase in the survival rate of children with high biological risk factors.

Early pain in preterm infants. A model of long-term effects

There are multiple lines of evidence suggesting that in vulnerable prematurely born infants, repeated and prolonged pain exposure may affect the subsequent development of pain systems, as well as potentially contribute to alterations in long-term development and behavior. Multiple factors cumulatively contribute to altered developmental trajectories in such infants. These include characteristics of the developing organism (low tactile threshold, sensitization, rapid brain development), characteristics intrinsic to the infant (gestation, illness severity), characteristics of the experience in the neonatal intensive care unit (pain exposure and cumulative stress), and characteristics of the caregivers within their family and social context. This article provides a model for examining long-term effects of pain in the newborn period embedded in a developmental context framework.

Antenatal prediction of intraventricular hemorrhage in fetal growth restriction: what is the role of Doppler?

OBJECTIVE

To evaluate relationships between neonatal intraventricular hemorrhage and altered brain blood flow in preterm growth-restricted fetuses.

METHODS

One hundred and thirteen growth-restricted fetuses (birth weight < 10th centile and umbilical artery pulsatility index > two standard deviations above gestational age mean) which delivered prematurely (< 34.0 weeks) were studied. Three expressions of altered brain blood flow were defined: 'brain sparing'= middle cerebral artery pulsatility index > two standard deviations below the gestational age mean, 'centralization' = ratio of middle cerebral artery/umbilical artery pulsatility indices (cerebroplacental ratio) > two standard deviations below the gestational age mean, and 'redistribution' = absent or reversed umbilical artery end-diastolic velocity. Intraventricular hemorrhage was graded after Papile (I-IV) by cranial ultrasound performed within 7 days of delivery.

RESULTS

Sixty-seven (59.3%) fetuses had brain sparing, 84 (74.3%) had centralization and 51 (45.1%) had redistribution. Fifteen (13.3%) neonates had intraventricular hemorrhage and were more likely to have a biophysical profile < 6, earlier delivery for fetal indications, lower cord artery pH, HCO3, hemoglobin, and platelets, a 10-min Apgar score < 7 and high perinatal mortality (5/15; 33.3%). No associations between intraventricular hemorrhage and brain sparing or centralization were identified. However, neonates with intraventricular hemorrhage had significantly higher umbilical artery pulsatility index deviations from the gestational age mean and a relative risk of 4.9-fold for intraventricular hemorrhage with redistribution (95% confidence interval, 1.5-16.3; P < 0.005). Multiple logistic regression revealed significant associations between intraventricular hemorrhage and a low 10-min Apgar score (r = 0.30, P < 0.005) and low hemoglobin (r = 0.28), gestational age at delivery (r = 0.25) and birth-weight centiles (r = 0.23) (P < 0.05). No Doppler parameter was identified as an independent contributor to intraventricular hemorrhage.

CONCLUSION

While loss of umbilical artery end-diastolic velocity early in gestation significantly increases the risk for neonatal intraventricular hemorrhage, prematurity and difficult transition to extrauterine life remain the most important determinants of intraventricular hemorrhage.

Growth and development in preterm infants fed long-chain polyunsaturated fatty acids: a prospective, randomized controlled trial

OBJECTIVES

A randomized, masked, controlled trial was conducted to assess effects of supplementing premature infant formulas with oils containing the long-chain polyunsaturated fatty acids, arachidonic acid (AA; 20:4 n6), and docosahexaenoic acid (DHA; 22:6 n3) on growth, visual acuity, and multiple indices of development.

METHODS

Infants (N = 470) with birth weights 750 to 1800 g were assigned within 72 hours of the first enteral feeding to 1 of 3 formula groups with or without long-chain polyunsaturated fatty acids: 1) control (N = 144), 2) AA+DHA from fish/fungal oil (N = 140), and 3) AA+DHA from egg-derived triglyceride (egg-TG)/fish oil (N = 143). Infants were fed human milk and/or Similac Special Care with or without 0.42% AA and 0.26% DHA to term corrected age (CA), then fed human milk or NeoSure with or without 0.42% AA and 0.16% DHA to 12 months' CA. Infants fed exclusively human milk to term CA (EHM-T; N = 43) served as a reference.

RESULTS

Visual acuity measured by acuity cards at 2, 4, and 6 months' CA was not different among groups. Visual acuity measured by swept-parameter visual-evoked potentials in a subgroup from 3 sites (45 control, 50 AA+DHA [fish/fungal]; 39 AA+DHA [egg-TG/fish]; and 23 EHM-T) was better in both the AA+DHA (fish/fungal; least square [LS] means [cycle/degree] +/- standard error [SE; octaves] 11.4 +/- 0.1) and AA+DHA (egg-TG/fish; 12.5 +/- 0.1) than control (8.4 +/- 0.1) and closer to that of the EHM-T group (16.0 +/- 0.2) at 6 months' CA. Visual acuity improved from 4 to 6 months' CA in all but the control group. Scores on the Fagan test of novelty preference were greater in AA+DHA (egg-TG/fish; LS means +/- SE, 59.4 +/- 7.7) than AA+DHA (fish/fungal; 57.0 +/- 7.5) and control (57.5 +/- 7.4) at 6 months' CA, but not at 9 months' CA. There were no differences in the Bayley Mental Development Index at 12 months' CA. However, the Bayley motor development index was higher for AA+DHA (fish/fungal; LS means +/- SE, 90.6 +/- 4.4) than control (81.8 +/- 4.3) for infants </=1250 g. When Spanish-speaking infants and twins were excluded from the analyses, the MacArthur Communicative Development Inventory revealed that control infants (LS means +/- SE, 94.1 +/- 2.9) had lower vocabulary comprehension at 14 months' CA than AA+DHA (fish/fungal) infants (100.6 +/- 2.9) or AA+DHA (egg-TG/fish) infants (102.2 +/- 2.8). There were no consistent differences in weight, length, head circumference, or anthropometric gains.

CONCLUSION

These results showed a benefit of supplementing formulas for premature infants with AA and DHA from either a fish/fungal or an egg-TG/fish source from the time of first enteral feeding to 12 months' CA.

Developmental outcomes of infants with bronchopulmonary dysplasia: comparison with other medically fragile infants

The purpose of this study was to compare the developmental outcomes and mother-infant interactions of infants with bronchopulmonary dysplasia (BPD) and those of other medically fragile infants. One-hour behavioral observations were made of the interactions of mothers with two groups of infants (23 with BPD, 39 medically fragile without BPD or neurological problems) at enrollment, every 2 months during hospitalization, 1 month after discharge, and at 6 months' and 12 months' corrected age. Assessment of the home environment also was done at 6 and 12 months. Multiple regressions were calculated separately for child mental, adaptive, language, and motor outcomes. Predictors were: home environment assessment, measures of maternal interactive behaviors (positive attention, expression of negative affect, medicalized caregiving), infant group membership, and presence of intraventricular hemorrhage (IVH) in the infant. There were no significant differences between the two groups in any of the developmental outcomes or interactive variables, and the presence of IVH had no effect on these variables. Maternal positive attention and the home environment were correlated with mental development, and mother negative affect was related to adaptive behavior for both groups. Differences in developmental and interactive behaviors between infants with BPD and other prematurely born infants found in other studies appear to be a result of chronic health problems and, thus, are not unique to infants with BPD.

Cognitive development of term small for gestational age children at five years of age

AIM

To assess the relative significance for cognitive development of small for gestational age, parental demographic factors, and factors related to the child rearing environment.

METHODS

IQ of a population based cohort of 338 term infants who were small for gestational age (SGA) and without major handicap, and a random control sample of 335 appropriate for gestational age (AGA) infants were compared at 5 years of age.

RESULTS

The mean non-verbal IQ was four points lower, while the mean verbal IQ was three points lower for the children in the SGA group. The results were not confounded by parental demographic or child rearing factors. However, parental factors, including maternal non-verbal problem solving abilities, and child rearing style, accounted for 20% of the variance in non-verbal IQ, while SGA versus AGA status accounted for only 2%. The comparable numbers for verbal IQ were 30 and 1%. Furthermore, we found no evidence that the cognitive development of SGA children was more sensitive to a non-optimal child rearing environment than that of AGA children. Maternal smoking at conception was associated with a reduction in mean IQ comparable to that found for SGA status, and this effect was the same for SGA and AGA children. The cognitive function of asymmetric SGA was comparable to that of symmetric SGA children.

CONCLUSIONS

Our findings indicate that child cognitive development is strongly associated with parental factors, but only marginally associated with intrauterine growth retardation.