Outcome in infants 501 to 1000 gm birth weight delivered to residents of the McMaster Health Region

Optic atrophy in prematurity: pathophysiology and clinical features

Optic atrophy is an important cause of visual impairment in children, and the aetiological profile has changed over time. Technological advancements led by neuroimaging of the visual pathway and imaging of the optic nerve with optical coherence tomography have accelerated the understanding of this condition. In the new millennium, an increasing prevalence of prematurity as a cause of optic atrophy in children has been highlighted. This new shift has been linked with increasing rates of premature births and improved neonatal survival of preterm infants. The available literature is limited to hospital and registry-based cohorts with modest sample sizes, methodological heterogeneity and selection bias limitations. Larger studies that are better designed are required to better understand the contribution of prematurity to the disease burden. In addition to considering other life-threatening aetiologies, screening for premature birth should be covered as part of a comprehensive history when evaluating a child with paediatric optic atrophy.

Behavioral Inhibition and Activation (BIS/BAS) Among Extremely Low Birth Weight Adult Survivors

Abstract. Although individual differences in behavioral inhibition and behavioral activation (BIS/BAS) are associated with differential risk of psychopathology in typical development, and extremely low birth weight (ELBW) survivors experience higher rates of psychopathology, measures of BIS/BAS have been largely unexplored in this population. As well, apparently no studies have examined the long-term stability of BIS/BAS in typical or atypical development. Ninety-nine ELBW survivors and 86 normal birth weight (NBW) control participants completed a measure of BIS/BAS at ages 22–26 and 30–35 years. At age 30–35 years we found that ELBW survivors scored lower on the BAS scale than NBW controls, but did not differ on the BIS scale. We also found evidence for long-term stability of BIS/BAS at the individual and rank-order levels, but not at the mean-level. These results highlight the importance of considering stability of motivational aspects of personality and also add to our understanding of how individual differences in these motivational tendencies may underlie psychopathology among ELBW survivors.

Brain, interrupted: alpha/delta EEG ratio in survivors of pre- and post-natal adversity

RESULTS

Young adults born at extremely low birth weight (prenatal adversity; N = 64, M_age = 23.14 years, SD_age = 1.26 years) had a lower alpha/delta ratio score compared to normal birth weight controls (N = 76, M_age = 23.60 years, SD_age = 1.09 years), while youth exposed to child maltreatment (postnatal adversity; N = 39, M_age = 16.18 years, SD_age = 1.15) had a higher alpha/delta ratio compared to controls (N = 23, M_age = 16.00 years, SD_age = 1.50 years).

CONCLUSIONS

Our results suggest that being exposed to pre- and post-natal adversity may have different long-term consequences on brain development. We speculate that these differences might be associated with some of the different functional outcomes known to characterize each type of adverse experience.

Shyness Trajectories across the First Four Decades Predict Mental Health Outcomes

Although childhood shyness is presumed to predict mental health problems in adulthood, no prospective studies have examined these outcomes beyond emerging adulthood. As well, existing studies have been limited by retrospective and cross-sectional designs and/or have examined shyness as a dichotomous construct. The present prospective longitudinal study (N = 160; 55 males, 105 females) examined shyness trajectories from childhood to the fourth decade of life and mental health outcomes. Shyness was assessed using parent- and self-rated measures from childhood to adulthood, once every decade at ages 8, 12-16, 22-26, and 30-35. At age 30-35, participants completed a structured psychiatric interview and an experimental task examining attentional biases to facial emotions. We found 3 trajectories of shyness, including a low-stable trajectory (59.4%), an increasing shy trajectory from adolescence to adulthood (23.1%), and a decreasing shy trajectory from childhood to adulthood (17.5%). Relative to the low-stable trajectory, the increasing, but not the decreasing, trajectory was at higher risk for clinical social anxiety, mood, and substance-use disorders and was hypervigilant to angry faces. We found that the development of emotional problems in adulthood among the increasing shy trajectory might be explained in part by adverse peer and social influences during adolescence. Our findings suggest different pathways for early and later developing shyness and that not all shy children grow up to have psychiatric and emotional problems, nor do they all continue to be shy.

Overprotective Parenting and Peer Victimization in Extremely Low Birth Weight Survivors

Extremely low birth weight (ELBW; <1000g) survivors are at increased risk for experiencing both peer victimization and overprotective parenting. This study investigated if overprotective parenting moderated associations between peer victimization and psychopathology among ELBW adult survivors who have been followed since birth. Participants included 81 (31 male, 50 female) adults born with an extremely low birth weight from Ontario, Canada. The participants were predominately Caucasian. The experience of peer victimization and overprotective parenting prior to age 16 was self-reported at age 22-26 years. Peer victimization was reported using the Childhood Experiences of Violence Questionnaire and overprotective parenting was reported using the Parental Bonding Instrument. Current anxiety disorder and alcohol or substance use disorder was assessed using the MINI International Neuropsychiatric Interview at age 29-36 years. The experience of overprotective parenting moderated the association between peer victimization and risk for an anxiety disorder in adulthood (OR=2.35, 95%CI, 1.01-5.50). If the ELBW survivor reported having an overprotective parent, peer victimization was associated with increased risk for having an anxiety disorder in adulthood (OR=2.45, 95%CI, 1.13-5.30). In contrast, this association was not significant in the absence of an overprotective parent (OR=1.04, 95%CI, 0.73-1.49). Future research should further investigate if parental support and encouragement of children's independence may be important for reducing the negative effects of peer victimization among ELBW survivors.

Exposure to overprotective parenting and psychopathology in extremely low birth weight survivors

BACKGROUND

Extremely low birth weight (ELBW; <1,000 g) infants are the most vulnerable babies and are at higher risk for experiencing overprotective (i.e., controlling and intrusive) parenting, which is hypothesized to contribute to the risk for mental disorders. Despite the increased risk for anxiety disorders and decreased risk for alcohol or substance use disorders seen in ELBW survivors, no research has examined the impact of parenting. This study investigated if overprotective parenting mediates links between ELBW birth status and psychiatric disorders in adulthood.

STUDY DESIGN

Participants included ELBW survivors born in 1977-1982 and matched normal birth weight (≥2,500 g) control participants (ELBW n = 81; normal birth weight n = 87) prospectively followed in Ontario, Canada. These individuals retrospectively reported on whether either of their parents was overprotective using the Parental Bonding Instrument. Presence of a current anxiety disorder and of current alcohol or substance use disorders was assessed using the Mini International Neuropsychiatric Interview at age 29-36 years.

RESULTS

Path analysis showed that overprotective parenting was a significant mediator of the association between ELBW status and risk for an anxiety disorder in adulthood and the risk for an alcohol or substance use disorder in adulthood in ELBW survivors. Overprotective parenting accounted for 53% of the association between ELBW status and the risk for an anxiety disorder in adulthood and 26% of the association between ELBW status and alcohol or substance use disorders.

CONCLUSIONS

Overprotective parenting accounted for a substantial proportion of the increased risk for anxiety and alcohol or substance use disorders in adulthood in ELBW survivors. Despite their perceived vulnerabilities, it is important that the parents of ELBW survivors be supported in their attempts to facilitate their children's pursuit of independence during childhood and beyond.

Long-term effects of peer victimization on social outcomes through the fourth decade of life in individuals born at normal or extremely low birthweight

Exposure to early adversity is known to have deleterious effects on brain-behaviour relations across the lifespan and across a range of domains. Here, we tested a cumulative risk hypothesis of adult social functioning and health outcomes in the fourth decade of life, using the oldest known longitudinally followed cohort of survivors of extremely low birthweight (ELBW; <1,000 g). We investigated the additional impact of peer victimization in youth on social outcomes at age 29-36 years in ELBW survivors and matched normal birthweight (NBW; >2,500 g) participants. In the combined sample, peer victimization was associated with lower likelihood of having children and household income, poorer family functioning and self-esteem, more loneliness and chronic health conditions, less social support, and increased likelihood for contact with police. Moderation analyses indicated that among ELBW survivors, compared to their NBW counterparts, victimization was more strongly associated with being convicted of a crime and with having chronic health conditions. These findings highlight the negative long-term impact of peer victimization on all children and that some outcomes may be differentially affected by prenatal and early post-natal environments. Statement of contribution What is already known on this subject Exposure to early adversity has deleterious effects on brain-behaviour relations across the lifespan. Extremely premature children have higher rates of exposure to adversities, including peer victimization. Peer victimization is associated with adverse outcomes in adulthood in those born at term. What does this study add? Victimization negatively impacts the social outcomes of those born extremely premature and at term into adulthood. Associations appear to be affected by individual differences in prenatal and early post-natal environments. Intervention is crucial when peer victimization occurs in children at risk, as well as those typically developing.

Adult social outcomes of extremely low birth weight survivors of childhood sexual abuse

Preterm birth and exposure to childhood sexual abuse (CSA) are early physiological and psychological adversities that have been linked to reduced social functioning across the lifespan. However, the joint effects of being born preterm and being exposed to CSA on adult social outcomes remains unclear. We sought to determine the impact of exposure to both preterm birth and CSA on adult social functioning in a group of 179 extremely low birth weight (ELBW; 2500 g) participants in the fourth decade of life. Social outcome data from a prospective, longitudinal, population-based Canadian birth cohort initiated between the years of 1977 and 1982 were examined. At age 29-36 years, ELBW survivors who experienced CSA reported poorer relationships with their partner, worse family functioning, greater loneliness, lower self-esteem and had higher rates of avoidant personality problems than those who had not experienced CSA. Birth weight status was also found to moderate associations between CSA and self-esteem (P=0.032), loneliness (P=0.021) and family functioning (P=0.060), such that the adverse effects of CSA were amplified in ELBW survivors. Exposure to CSA appears to augment the adult social risks associated with perinatal adversity. Individuals born preterm and exposed to CSA appear to be a group at particularly high risk for adverse social outcomes in adulthood.

Adult mental health outcomes of child sexual abuse survivors born at extremely low birth weight

The high prevalence of child sexual abuse (CSA) is concerning, particularly as survivors are at increased risk for multiple adverse outcomes, including poor mental health across the lifespan. Children born at an extremely low birth weight (ELBW; <1000g) and who experience CSA may be a group that is especially vulnerable to psychopathology later in life. However, no research has considered the mental health risks associated with being born at ELBW and experiencing CSA. In this study, we investigated the mental health of 179 ELBW survivors and 145 matched normal birth weight (NBW; >2500g) participants at ages 22-26 and 29-36. At age 22-26, CSA was associated with increased odds of clinically significant internalizing (OR=7.32, 95% CI: 2.31-23.23) and externalizing (OR=4.65, 95% CI: 1.11-19.51) problems among ELBW participants exposed to CSA compared to those who did not, though confidence intervals were wide. At age 29-36, CSA was linked to increased odds of any current (OR=3.43, 95% CI: 1.08-10.87) and lifetime (OR=7.09, 95% CI: 2.00-25.03) non-substance use psychiatric disorders, however, this did not hold after adjustment for covariates. Statistically significant differences in mental health outcomes were not observed in NBW participants exposed to CSA compared to NBW participants who were not exposed. Survivors of significant perinatal adversity who are also exposed to CSA may be at higher risk for psychopathology through the fourth decade of life.

High-Frequency Ventilation in Newborn Infants

In the past mechanical ventilation always mimicked the tidal volumes and ventilatory frequencies of normal breathing. Recently, there has been great interest in techniques that use rapid rates (60 to 3,000 per minute) and tidal volumes approximating dead space. These techniques are known collectively as high-frequency ventilation, although they differ in circuit design, use, potential complications, and mechanism of gas transport. High-frequency ventilation can be divided into four categories: (1) high-frequency positive pressure ventilation, (2) high-frequency jet ventilation, (3) high-frequency oscillatory ventilation and high-frequency flow interruption, and (4) high-frequency chest wall oscillation. In this review we discuss the similarities and differences of these high-frequency techniques, their clinical applications, and some physiological mechanisms involved in gas transport.

Parenting and Family Support in Japan for 6- to 8-year-old Children Weighing under 1000 Grams at Birth

The purpose of this study was to explore the variables related to paternal involvement in the caregiving of 6- to 8-year-old extremely low-birthweight (ELBW) children, specifically, sociodemographic factors related to the family or individual biological factors related to ELBW. Thirty-three children with a mean birthweight of 845.5 grams and a mean gestational age of 27.4 weeks participated in this research. Approximately 29% of their fathers were classified by the mothers as nonco-operative in overall child care. The paternal involvement in caregiving was related to the sociodemographic variables of the family; the co-operative fathers were proportionally more often from families where the child had no older female sibling(s) and/or grandparent(s), whereas the nonco-operative fathers were proportionally more often from families where the child had older female sibling(s) and/or grandparent(s). The individual perinatal risk variables and IQ, and the paternal variables (age, socioeconomic status) were not related to the paternal co-operativeness. Our sample mothers seemed to have raised their children in more difficult parenting and economic situations, and to have received proportionally more support from grandparent(s) than did typical Japanese mothers. The children's relationships with peers differed between the paternal co-operative and nonco-operative groups; there were proportionally more children from the nonco-operative group who preferred to play alone than to play with peer(s) at the ages of 3-5 years. Thus, scarce paternal involvement in the process of caregiving appeared to influence the children's sociability.

Long-term Psychiatric Impact of Peer Victimization in Adults Born at Extremely Low Birth Weight

BACKGROUND

While children born at extremely low birth weight (ELBW; <1000 g) are at elevated risk for peer victimization, no research has examined its effects on mental health in adulthood.

METHODS

ELBW survivors and matched normal birth weight (NBW; >2500 g) controls were part of a prospective, population-based study in Ontario, Canada. Peer victimization before age 16 was self-reported at age 22 to 26 years by using a 10-point measure. Presence of psychiatric disorders was examined at age 22 to 26 years (ELBW n = 142, NBW n = 133) and age 29 to 36 years (ELBW n = 84, NBW n = 90).

RESULTS

After adjustment for confounding variables, for each 1-point increase in the peer victimization score, ELBW survivors had increased odds of current depressive (odds ratio [OR] = 1.67, 95% confidence interval [CI], 1.23-2.28), anxiety (OR = 1.36, 95% CI, 1.05-1.76), avoidant (OR = 1.39, 95% CI, 1.08-1.79), antisocial (OR = 1.92, 95% CI, 1.06-2.87), and attention-deficit/hyperactivity (OR = 1.39, 95% CI, 1.06-1.83) problems at age 22 to 26 years. At age 29 to 36 years, peer victimization score predicted increased odds of current panic disorder (OR = 1.69, 95% CI, 1.01-2.83) and obsessive-compulsive disorder (OR = 3.56, 95% CI, 1.25-10.09). For NBW controls, peer victimization predicted increased odds of antisocial problems at age 22 to 26 years.

CONCLUSIONS

ELBW survivorsand NBW participants are vulnerable to the adverse psychiatric effects of childhood peer victimization in adulthood.

Refraction and visual acuity in a national Danish cohort of 4-year-old children of extremely preterm delivery

PURPOSE

A recent threefold increase in laser treatment for advanced retinopathy of prematurity (ROP) triggered a nationwide preschool ophthalmic and developmental status among extremely preterm survivors. Here, we discuss refraction and visual acuity.

METHODS

Survivors (n = 178) from a national birth cohort (February 2004 to March 2006) of gestational age <28 weeks (PT) and 56 full-term (FT) controls attended for evaluation at age 4 years. Cycloplegic refraction and keratometry were achieved by Retinomax autokeratorefractor and visual acuities by symbol recognition (HOTV, logMAR).

RESULTS

The refractive distribution presented a myopic tail (4.5%) and a hyperopic tail (11.9% ≥+2.5 D) as special preterm features, and corneas were more curved. Astigmatism and anisometropia were only marginally increased, and visual acuities were generally good. Best-corrected binocular median logMAR visual acuity was 0.1 in FT and 0.2 in PT, in Snellen equivalents 0.8 and 0.63. Snellen acuity ≤0.5 occurred across the ROP subgroups, but mainly in those with at least ROP stage 3. Two children had low vision.

CONCLUSIONS

The overall fair outcome for refraction and function is in accordance with other recent northern Europe experience. The results differ in particular from the poorer ophthalmic outcomes reported in the pioneer US treatment studies (cryotherapy for ROP and ETROP). The diode laser ablations (n = 32) appeared effective in our series; except one child, all treated subjects had good or fair social vision at the age of 4 years.

Maternal antenatal profile and immediate neonatal outcome in VLBW and ELBW babies

OBJECTIVE

To evaluate the antenatal profile of the mother and the immediate neonatal morbidity and mortality till discharge.

METHODS

The study was a retrospective analysis of 92 patients of preterm labour who delivered babies weighing

RESULTS

A total of 92 mothers in preterm labour at 26 to 34 weeks were admitted and subsequently delivered 70 VLBW babies (< 1500 gms) and 36 ELBW babies (< 1000 gms) including 8 pairs of twins and 3 triplets pregnancies. Majority of the patients (93.4%) were booked. Amongst the various high risk factors for preterm labour, anaemia during pregnancy (32.6%), bacterial vaginosis (26%), gestational hypertension (18.4%) and pervious history of preterm labour (18.4%) were common associations. Calcium channel blocker (Depin) tocolysis was effective in postponing labour from 48 hours to more than 2 weeks. The cesarean section rate was very high (67.3%) in our study. The commoner neonatal complications in both VLBW and ELBW babies were RDS, neonatal jaundice and sepsis. Features of IUGR were seen in both the groups (22.8% in VLBW and 22.2% in ELBW babies). The neonatal mortality rate till discharge was 15.7% in VLBW group and 33.3% in ELBW group. The morality rate was highest in 26 to 30 weeks gestation babies and in babies weighing < 800 gms.

CONCLUSION

Antenatal profile of preterm labour in our series showed a number of high risk factors. The identification of common high risk factors is important for appropriate prenatal care. A better neonatal survival rate was possible due to timely intervention, appropriate management and NICU care facility available in our tertiary care centre.

Maternal and neonatal profile and immediate outcome in extremely low birth weight babies in Delhi

We studied the maternal and neonatal profile and outcome of extremely low birth weight (ELBW) babies at the level III neonatal intensive care unit (NICU) in Delhi. Case records of ELBW inborn babies delivered between August 2000 and August 2001 were analysed by using a pre-set proforma. A total of 52 ELBW babies were admitted to the NICU in the relevant period, of whom 30 (57%) survived. Maternal anaemia, previous preterm delivery and pregnancy-induced hypertension (PIH) were the common predisposing factors for preterm delivery. Mean gestational age was 27.8 weeks and mean birth weight was 831 g. The highest mortality (55%) was seen in babies with 26-28 weeks'gestation and those in the birth weight category of < 800 g. Neonatal hyperbilirubinaemia (78%) and hyaline membrane disease/respiratory distress syndrome (65%) were the most common causes of morbidity. A total of 25 babies were mechanically ventilated while 24 (46%) received total parenteral nutrition. Sepsis, pulmonary haemorrhage, intracranial haemorrhage and necrotizing enterocolitis accounted for the deaths in the study population. Retinopathy of prematurity screening was performed in 35 babies (68%), of whom 22 were found to be normal. According to the International Classification of Retinopathy of Prematurity, most babies (72%) had involvement of zone 3 and stage I (63%). The incidence was highest in 26-28 weeks'gestation babies (71%) and the < 800 g birth weight category (62%). Maternal risk factors such as anaemia and PIH commonly predispose to preterm delivery. There is an alarmingly high mortality in this population. Effective steps are required not only to avoid extreme prematurity but also to reduce morbidity and mortality of all newborns weighing <1000 g at birth.

Trends in the incidence of severe retinopathy of prematurity in a geographically defined population over a 10-year period

OBJECTIVE

To examine trends in the incidence of severe (> or =grade 3) retinopathy of prematurity (ROP) in infants with birth weight of < or =1250 g in a geographically defined population over a 10-year period.

METHODS

An observational study was conducted of all infants who had a birth weight < or =1250 g and were born to mothers who were resident in the county of Leicestershire, United Kingdom, during the period January 1, 1990, to December 30, 1999. Cases were identified by the Trent Neonatal Survey. The incidence of severe ROP (> or =grade 3) was compared in 2 successive 5-year periods: 1990-1994 and 1995-1999.

RESULTS

Comparing the first 5-year period (1990-1994) with the second (1995-1999), the total number of live births fell (60 789 vs 56 564). However, there was a significant increase in the number of births with birth weight < or =1250 g (including live and dead; 615 vs 734; live births only: 455 vs 556). Survival to 42 weeks of infants who were born at < or =1250 g was significantly better in the latter time period (203 vs 302; odds ratio [OR] for death: 0.54; 95% confidence interval [CI]: 0.39-0.75). The number of cases of severe ROP was 4 times higher during the second time period compared with the first (9 vs 36). A significantly increased risk for the development of severe ROP was seen during the second time period (OR: 2.92; 95% CI: 1.37-6.20). Even after allowing for the change in gestation induced by the improved survival during the second time period, the increased risk remained (OR: 2.81; 95% CI: 1.27-6.21).

CONCLUSIONS

There is strong evidence that the incidence of severe ROP among infants with birth weight < or =1250 g increased in the latter half of the last decade. The increased risk seems to be independent of the increase in survival.

Neonatal survival rates in 860 singleton live births at 24 and 25 weeks gestational age. A Canadian multicentre study

OBJECTIVE

To determine the current survival rate of singleton living newborns born at gestational age of 24 and 25 weeks, using obstetric factors available to the physician before birth.

DESIGN

Retrospective study of all live births in 13 of 17 Canadian tertiary centres. Population All singleton live births without congenital abnormalities.

METHODS

During the years 1991-1996, data were abstracted from clinical databases and charts of 860 live births, in 13 of the 17 tertiary centres in Canada, all with major neonatal intensive care units. Newborn survival was defined as alive at discharge from neonatal intensive care unit. Abstracted elements included gestational age, maternal antenatal corticosteroid treatment, birthweight, gender, fetal presentation and mode of delivery.

RESULTS

Average survival rates increased from 56.1% at 24 weeks (n = 406) to 68.0% at 25 weeks (n = 454). Survival rates ranged from 53.1% at day 168 to 81.6% at day 181 (r = 0.802, P < 0.05). Steroid administration improved the survival rates at 24 and 25 weeks compared with that of unexposed fetuses, respectively (58.9% vs 41.8%; OR 1.70; 95% CI 1.03-2.08 and 74.2% vs 56.8%; OR 2.19; 95% CI 1.41-3.38). Caesarean delivery for breech presentation improved survival compared with vaginal delivery, both at 24 and 25 weeks (56.1% vs 36.0%; OR 2.19; 95% CI 1.10-4.34, and 68.7% vs 55.2% OR 1.78; 95% CI 0.093-3.43). Female neonates displayed better survival rates (59.6% vs 52.1% OR 1.36; 95% CI 0.92-2.01, and 72.6% vs 63.1% OR 1.51; 95% CI 1.02-2.25) at 24 and 25 weeks, respectively. Explanatory regression model confirmed these factors as prognostic variables associated with survival.

CONCLUSIONS

This extensive collaborative study confirms that several prognostic factors, known before birth, including gestational age in days, steroid treatment, mode of presentation and fetal sex may help obstetricians, neonatologists and parents in their decision-making process at 24 and 25 weeks of pregnancy.

Ocular fundus abnormalities in children born before 29 weeks of gestation: a population-based study

PURPOSE

Preterm birth has been found to be associated with increased morbidity of the central nervous and vascular tissues. To investigate the influence of preterm birth on the optic disc and retinal vessels, we examined the ocular fundus in school-aged children born very preterm.

METHODS

A prospective, population-based study was performed in 50 very preterm children (median age 7 years, range 5-9 years) with a median gestational age at birth of 27 weeks (range 24-28 weeks) and a median birth weight of 1055 g (range 450-1520 g). The ocular fundus was examined by ophthalmoscopy in 50 children, and the optic nerve and retinal vessel morphology was evaluated by digital image analysis of ocular fundus photographs in 45 of these children.

RESULTS

The median optic disc area was significantly smaller (p = 0.0002) in the preterm children compared with a reference group. There was no difference in cup area and, consequently, the rim area was significantly smaller (p = 0.0002) in the preterm children. Children with early signs of brain lesions commonly had a rim area below the median of the reference group. Preterm children also commonly had an abnormal retinal vascular pattern that was independent of a previous history of retinopathy of prematurity.

CONCLUSION

Very preterm birth was associated with subnormal optic disc and rim areas and an abnormal vascular pattern. The findings clearly demonstrate the effect of preterm birth on the development of these structures. The long term clinical prognosis of these findings has yet to be determined.

Anaerobic performance in 5- to 7-yr-old children of low birthweight

PURPOSE

This study was intended to determine whether anaerobic muscle performance is deficient in 5- to 7-yr-old children of extremely low birthweight (ELBW, 500-999 g) and very low birthweight (VLBW, 1000-1499 g).

METHODS

Fourteen ELBW and 20 VLBW children were compared with 24 normal birthweight (NBW, >2500 g) term controls. Peak (PP) and mean (MP) muscle power were determined by the Wingate anaerobic test. Bioimpedance analysis and anthropometry were done to assess fat-free mass (FFM) and lean cross-sectional area of the thigh and calf.

RESULTS

The ELBW group had significantly lower MP and PP, compared with the VLBW and, in particular, with the NBW group. This lower performance was apparent also when values were corrected for total body mass (MP) and FFM (MP and PP), but not when corrected for cross-sectional area of thigh and calf.

CONCLUSION

The lower anaerobic muscle performance in ELBW children may be partly due to their smaller muscle mass, but may also reflect a low percentage of fast-twitch muscle fibers, low muscle phosphagen content, or deficiency in motor control.

Population-based study of infants born at less than 28 weeks' gestation in New South Wales, Australia, in 1992-3. New South Wales Neonatal Intensive Care Unit Study Group

The aims of the study were to use the population base of New South Wales (NSW) to study all births from 20 to 27 weeks' gestation in 1992-3 and to compare two data sources for perinatal deaths. The prospective population-based statewide audit (NICUS) of infants admitted to tertiary neonatal intensive care units (NICUs) in NSW was used to collect data on infants less than 28 weeks' gestation registered in 1992-3. This audit also surveyed the 160 obstetric hospitals in NSW to ascertain information on stillbirths and early neonatal deaths in the study period. The NSW midwives data collection (MDC) was the other source of information on stillbirths and labour ward deaths. Data were analysed using SAS. In 1992-3 in NSW 1170 infants were born at 20-27 weeks' gestation. There were 556 stillbirths and 614 live births, of whom 180 (29.3%) died in the labour ward and 434 (70.7%) were admitted to a tertiary NICU. Sixty-six per cent of stillbirths were identified by both data collections, 16.5% by the MDC only and 17% by NICUS only. There was a high major congenital anomaly rate (18.5%) among the stillbirths. Two-thirds of the infants admitted to NICUs survived to 1 year. Information was available on at least one follow-up parameter for 89% (255/288) of the survivors to 12 months (corrected age). Of the 244 infants who had a neurological assessment by a paediatrician, 17% were diagnosed to have cerebral palsy. Eleven per cent of the 239 who had a formal Griffiths developmental assessment had a major intellectual disability. Five (2% of 255) of the 1-year-olds were blind, and 12 (4.7% of 255) had bilateral hearing aids. Seventy-one per cent of the infants examined at 1 year did not have a major disability. For accurate perinatal death data, collection from more than one source is recommended. Infants born at 20-27 weeks' gestation contribute 40% of all stillbirths in NSW, most of the costs of neonatal intensive care as well as the costs of long-term morbidity. In Australia in the early 1990s, the survival of infants born at less than 28 weeks' gestation was best from 26 weeks gestational age onwards. Long-term morbidity did not change from that of earlier cohorts. The most common major disability was cerebral palsy.

Atypical chronic lung disease patterns in neonates

OBJECTIVE

To determine, in the postsurfactant era, the incidence and clinical characteristics of infants with atypical versus traditionally defined bronchopulmonary dysplasia (BPD) among premature infants with birth weights <1251 g.

DESIGN

Retrospective cohort study.

SETTING

A single regional neonatal intensive care unit (level III/IV).

PATIENTS

Two hundred thirty-two premature infants <1251 g at birth consecutively admitted during a 2-year period.

MAIN OUTCOME MEASURE

Incidence of classic BPD and atypical chronic lung disease (CLD) (occurring without preceding respiratory distress or after recovery from respiratory distress).

RESULTS

Among 177 infants <1251 g who survived to 28 days, 27 (15%) had atypical CLD and 61 (34.5%) had classic BPD. Atypical CLD infants were significantly heavier and more mature than classic BPD infants (mean birth weights, 922 +/- 152 g vs 854 +/- 173 g; and mean gestational age, 26.8 +/- 1.3 weeks vs 26.1 +/- 1.6 weeks). Median duration of ventilator support (31 days; range, 2 to 127 vs 42 days; range, 4-145 days) and oxygen therapy (30 days; range, 11 to 163 vs 48 days; range, 19-180 days) were shorter in atypical CLD infants than in classic BPD infants.

CONCLUSION

Atypical CLD comprised 31% of total cases of CLD. Atypical CLD appears to be less severe than classic BPD. These data suggest that initial, acute lung injuries are not the sole antecedents of neonatal CLD.

Neuromotor ability in 5- to 7-year-old children with very low or extremely low birthweight

This study was intended to determine the effects of extremely low birthweight (ELBW, 500 to 999 g) and very low birthweight (VLBW, 1000 to 1499 g) on neuromotor ability in 5- to 7-year-old children. Fourteen ELBW and 20 VLBW children were compared with 24 term control children of normal birthweight (NBW, >2500 g). Using quantitative assessment instruments, the following data were collected: maximal cycling speed during 30 seconds of cycling at 'zero' resistance, simple reaction time of the legs, and performance on components of a whole-body coordination test. The main findings were a slower reaction time, lower maximal cycling speed, and lower coordination scores in the ELBW group compared with the NBW group and, for some variables, with the VLBW group. The reduced motor performance in these children appears for the most part to be a reflection of impaired neuromotor control and motor development, rather than merely a smaller body or muscle size.

Ethical issues in the care of extremely low birth weight infants

This article examines the difficulties in making decisions about the medical treatment of infants who have uncertain viability because of extremely low birth weight. The advantages and disadvantages of three systematic approaches are reviewed. An approach called "provisional intensive care for all" may offer the most benefit and cause the least harm. With this approach, all liveborn infants would be presumed viable and would receive intensive care, at least initially. After further assessment of the infant, the parents would be informed as fully as possible about the possible outcome of continuing intensive care. The treating physicians would offer the parents the options of continuing intensive care or withdrawing it and providing basic care. Although the physicians would provide recommendations based on their best medical judgment, they would be prepared to support and carry out the parents' decision.

Infectious causes of chronic inflammatory diseases and cancer

Powerful diagnostic technology, plus the realization that organisms of otherwise unimpressive virulence can produce slowly progressive chronic disease with a wide spectrum of clinical manifestations and disease outcomes, has resulted in the discovery of new infectious agents and new concepts of infectious diseases. The demonstration that final outcome of infection is as much determined by the genetic background of the patient as by the genetic makeup of the infecting agent is indicating that a number of chronic diseases of unknown etiology are caused by one or more infectious agents. One well-known example is the discovery that stomach ulcers are due to Helicobacter pylori. Mycoplasmas may cause chronic lung disease in newborns and chronic asthma in adults, and Chlamydia pneumoniae, a recently identified common cause of acute respiratory infection, has been associated with atherosclerosis. A number of infectious agents that cause or contribute to neoplastic diseases in humans have been documented in the past 6 years. The association and causal role of infectious agents in chronic inflammatory diseases and cancer have major implications for public health, treatment, and prevention.

The evaluation of percutaneous central venous catheters--a convenient technique in pediatric patients

OBJECTIVE

To evaluate the feasibility and effectiveness of 3 different types of silastic catheters that were used for percutaneous central venous catheterization (PCVC) through peripheral veins.

DESIGN AND SETTING

The study was prospective and consecutive for 6 years at a pediatric/neonatal intensive care unit and pediatric ward in Veterans General Hospital-Taipei, a university-affiliated medical center, in Taiwan, ROC.

PARTICIPANTS AND INTERVENTIONS

The patients who had PCVC were consecutively enrolled from January 1988 to December 1993. Three types of silastic catheters were used. The classification was according to the caliber as small catheter (SC, 0.30 mm ID), mid-size catheter (MC, 0.51 mm ID) and large catheter (LC, 0.64 mm ID). The same insertion technique, catheter-through-needle, was used for all PCVC placements through the peripheral vein. After insertion, each catheter was connected to a conventional short cannula (24-, 22-, or 20-gauge) of compatible caliber, and then linked to the infusion system.

RESULTS

1318 PCVCs were used in 1126 consecutive patients, that included 754 SCs in 649 infants (among them 60.9% were less than 1500 g), 383 MCs in 319 toddlers, and 181 LCs in 158 children. Mean (SD) body weight at the time of catheter insertion was SC 1.7(0.9)kg, MC 12.1(6.5)kg and LC 19.3(7.6)kg. Overall, mean (SD) duration of these PCVC was 16.4(8.4) days. A significantly longer duration was noted in: (a) SC group with 19.7(10.4) days than the other two groups [MC 12.4(6.5) days, LC 11.2(5.0) days]; (b) patients with body weight equal to or less than 3.0 kg [18.7(8.6) versus 14.1(6.1); and (c) insertion sites other than external jugular vein (EJV) [18.8(9.7) versus 11.7(6.0)]. These PCVCs provided reliable venous access for multiple purposes such as hyperalimentation, venous access or sampling of blood, antibiotic therapy and chemotherapy. MC and LC were also used for monitoring the central venous pressure. Most of the time, SC and MC were inserted through the superficial peripheral vein of the scalp, neck and extremities, while LC was almost approached via the EJV. The overall success rate of insertion was 92.4% (1318/1427). No significant difference was observed among the different catheter groups [93.4% (754/807) in SC, 90.5% (383/423) in MC and 91.9% (181/197) in LC] and the different insertion sites. Within each group of PCVC, more than eighty percent of catheters were removed electively: 83.3% in SC, 89.6% in MC and 84.5% in LC. Probable catheter-related sepsis accounted for 2.7% (36/1, 318) of all PCVCs. With this study, the cost of each PCVC set is 3.0 US dollar.

CONCLUSION

This study indicates that the use of three different calibers of silastic catheter is feasible and effective for PCVC in pediatric practice.

Vineland Adaptive Behavior Scales as a summary of functional outcome of extremely low-birthweight children

This study reports moderate to high Pearson correlations between Vineland Adaptive Behavior Scale (VABS) subscale and total scores and a variety of cognitive, academic and motor performance tests on a population of extremely low-birthweight infants assessed at eight years of age. The subscales describe adaptive behaviour in daily living, communication, motor function and socialization, as well as an adaptive behaviour composite score. Because it can provide a norm-referenced description of functional outcomes and can be used to assess all children regardless of disability, the authors believe that the VABS should be applied uniformly by all groups reporting school-age outcome of neonatal intensive-care populations.

Visual deficits in children born at less than 32 weeks' gestation with and without major ocular pathology and cerebral damage

AIMS

A study was carried out to compare the visual abilities of prematurely born children with those of matched full term controls.

METHODS

The vision of 68 children born at less than 32 weeks' gestation and aged between 5 and 7 1/2 years at the time of testing was compared with that of a control group of children born at full term, and matched for sex and age from due date.

RESULTS

The premature children had significantly poorer distance and near visual acuity, contrast sensitivity and stereopsis, and a high incidence of colour vision defects (predominantly tritan type). These differences were associated with the high incidence of ocular pathology experienced by 31 (45%) of the premature children compared with only nine (13%) of the controls. When excluding children with ocular and cerebral pathology, 32 matched pairs of premature and control children remained. The 32 premature children did not differ from their controls in terms of distance and near acuities or stereopsis, but they did have significantly poor contrast sensitivity in both their 'best' and 'worst' eyes. None of the 32 control children had colour vision defects, compared with seven of the matched premature children.

CONCLUSION

This adds support to previous speculation that the preterm eye is at risk of subtle visual impairment independent of the occurrence of refractive error, manifest squint, disorders of the fundus and media, and cerebral damage.

Improving outcome for Western Australian infants with birthweights 500-999 g

OBJECTIVE

To assess changes in survival and disability in liveborn extremely low birthweight infants (500-999 g) in Western Australia, 1980-1987.

DESIGN

Cohort study comparing two periods, 1980-1983 (P1) and 1984-1987 (P2).

PARTICIPANTS

All 586 liveborn extremely low birthweight infants in WA in 1980-1987 (266 in P1, 320 in P2).

MAIN VARIABLES EXAMINED

Birthweight, place of birth, age at death, neurosensory examination findings and scores on the Griffiths Mental Development Scales or other standardised test results.

RESULTS

482/586 infants (82%) were born at King Edward Memorial Hospital (KEMH), a level III referral centre, and a further 4% were transferred there after birth. The proportion born at KEMH increased from 78% in P1 to 86% in P2. Survival increased from 35% to 43% overall. In those below 800 g birthweight, survival doubled from 14% to 29%. There was no change in the age at death for non-survivors. Follow-up information was known for 222 of the 229 survivors at median ages of 46 months (P1) and 43 months (P2). Disability rates in infants below 800 g birthweight remained static (P1, 26%; P2, 28%), but fell in those of 800-999 g birthweight from 24% to 13%. Overall, survival free of disability increased from 26% to 34%.

CONCLUSION

Increased survival rates occurred without any increase in the rate or severity of disability in survivors.

Decreasing perinatal mortality: unchanged infantile spasm morbidity

The present study examined whether changes in the incidence of infantile spasms could be used to evaluate changes in the quality of pre- and perinatal care over time. 107 children in 1960 to 1976, and 102 in 1977 to 1991, developed infantile spasms in southern Finland. The number of small-for-gestational age (SGA) infants and infants with neonatal hypoglycaemia decreased significantly. Brain malformations, malformation syndromes and patients with tuberous sclerosis increased; this probably reflects the development of more refined neuroradiological screening methods. SGA infants are probably more apt to develop infantile spasms than preterm infants appropriate for gestational age. Early prenatal factors seem to play a major role in the genesis of infantile spasms. Little can be done to reduce the incidence of infantile spasms, but every effort should be made to reduce the number of SGA infants by good prenatal care. Treatment of hypoglycaemia is important because infantile spasms might be preventable in these infants.

[Handicaps and the perinatal period. II. Perinatal pathology and severe deficiencies]

BACKGROUND

In the last two decades, the infant mortality rate has dramatically declined. But improved management of newborns may induce an increased prevalence of neurodevelopmental handicaps. The aim of this paper is to estimate the rate of major disabilities and their relationships to perinatal events.

POPULATION AND METHODS

Three hundred and sixteen children born in 1984 and registered by the "Commission Départementale de l'Education Spéciale" (CDES) were included in the study. Among these, 97 had either cerebral palsy, blindness, deafness, or mental retardation. These 97 children were compared to 602 school age controls using a multivariate analysis (logistic regression).

RESULTS

The rate of major disabilities among the 6-year old children is 3.4/1000. It was 5/1000 in 1972 and 4.3/1000 in 1976. This frequency is higher in the children who were preterm (odds ratio--OR = 4.8), small for gestational age (OR = 3.3) or suffered from perinatal asphyxia (OR = 32.8). These three factors accounted for 37.4% of major disabilities.

CONCLUSION

This study emphasizes the relationships between perinatal events and some major handicaps but also shows that antenatal factors may be involved in neurodevelopmental problems.

Comparison of mortality and rates of cerebral palsy in two populations of very low birthweight infants

Comparisons of mortality and rates of cerebral palsy in different populations can be confusing. This is illustrated by comparing two populations of very low birthweight infants born in the 1980s, one from the Netherlands, the other from the UK (Oxford region). Although a number of biases were controlled for while comparing two large geographically defined populations, by assessing the survivors at similar ages and describing their health status in a standard way, some problems in interpretation of outcome remained. Differences in registration practice of live births at early gestational ages, as well as differences in withholding or withdrawing treatment, which occurred in about half of the cases of neonatal death in the Netherlands and in about one third of those in the Oxford region, may have influenced the incidence of registered live births, neonatal mortality, and the rate of cerebral palsy.

Outcome of infants born preterm, with special emphasis on extremely low birthweight infants

The outcome of extremely low birthweight (ELBW) infants has been reviewed from published articles and up-to-date data from Japan. The mortality rate of these infants declined significantly from over 90% to below 50% after the introduction of intensive care in the 1970s, but the incidence of major neurological sequelae remained steady at around 20%. Similarly, the incidence of major neurological sequelae did not increase along with the decrement of birthweight, although the mortality rate increased significantly. Long-term follow-up of ELBW children until school age has revealed poor school performance in spite of the absence of major neurological sequelae and the attainment of average intelligence quotient scores. Physical growth is retarded initially but generally catches up by the age of 8-9 years. In Japan, the neonatal mortality rate of ELBW infants declined from 56% in 1981 to 25% in 1989 with an increased birth rate of ELBW infants. In ELBW infants cared for at Tokyo Women's Medical College during 1984-90, the survival rate was 112 out of 134 (84%) and the incidence of major neurological sequelae was 15 out of 87 (17%) at 1-8 years old. The viability limit of ELBW infants has been discussed based on recent data. As a result of the rapid progress of medical care of ELBW infants, their viability limit as defined in the Eugenic Protection Law in Japan was amended from 24 completed weeks of gestation to 22 completed weeks in 1991.

Functional abilities at age 4 years of children born before 29 weeks of gestation

OBJECTIVES

To assess the rate of impairment and disability among babies born very preterm and to investigate the association between such impairment and gestational age at birth.

DESIGN

Cohort study of a geographically defined population of babies.

SETTING

Oxford Regional Health Authority.

SUBJECTS

All babies born alive before 29 weeks of gestation to mothers resident in the region during 1984-6.

MAIN OUTCOME MEASURES

Survival rates and rates of impairment and disability among survivors at the age of 4 years.

RESULTS

Of the 342 babies, half (170) survived to be discharged home. Of the 164 survivors to age 4 years, 153 (93%) were assessed. A total of 35 (23%; 95% confidence interval 16% to 30%) were severely disabled and only 54 (35%; 28% to 43%) were unimpaired. The risk of impairment and disability increased with decreasing gestational age at birth (p < 0.003).

CONCLUSIONS

With the increasing survival rate among babies born before 29 weeks of gestation, we need urgently to establish reliable ways of monitoring the proportion of survivors who have a disability.

The high-risk infant

A large number of infants are born each year with biologic or environmental risk factors that put them at increased risk for developmental disability, although most do not go on to have major disabilities. Some risk factors, for example, intraparenchymal hemorrhage, periventricular cysts, encephalomalacia, and abnormal neurodevelopmental examination, carry a much higher risk of developmental disability than others. There is much overlap among risk factors, and infants with multiple risk factors generally have a greater risk of disability than infants with just a single risk factor. All high-risk infants should receive careful pediatric follow-up that includes developmental screening, but efficient use of so far quite limited resources argues for selection of the highest risk infants for comprehensive developmental follow-up or early intervention programs. A system of tracking and monitoring high-risk infants during infancy and childhood would allow for early identification of developmental delay and appropriate referral for community resources.

Hearing loss in very preterm and very low birthweight infants at the age of 5 years in a nationwide cohort

In a geographically defined population of very preterm and very low birthweight infants (gestational age < 32 weeks and/or birthweight < 1500 g) hearing was evaluated in 890 children by pure-tone audiometry at the age of 5 years. Hearing loss was conductive/unspecified in 123 (13.8%) and sensorineural in 13 (1.5%) children. The prevalence of sensorineural hearing loss was 15 times as high as in 5-7 year old children in the Dutch population at large. The sensorineural hearing loss prevalence in very low birthweight and extremely low birthweight infants was similar. On account of communication disorders 10 (1.1%) children were classified as disabled and 6 (0.7%) as handicapped, following the definitions of the International Classification of Impairments, Disabilities, and Handicaps of the World Health Organisation. Children with conductive hearing loss had a higher risk of impairments, disabilities and handicaps of language and speech development, than children with normal hearing, the difference being statistically significant. The same holds for children with sensorineural hearing loss; moreover they had a significantly higher risk of impairments, disabilities and handicaps of mental development. Overall comparison of children with and without sensorineural hearing loss proved that the children with sensorineural hearing loss had a significantly less favourable outcome, based on 15 perinatal factors simultaneously. The age at which sensorineural hearing loss in very preterm and/or very low birthweight infants is detected has to be improved.

Evaluation of care for the preterm infant: review of literature on follow-up of preterm and low birthweight infants. Report from the collaborative Project on Preterm and Small for Gestational Age Infants (POPS) in The Netherlands

Since the introduction of neonatal intensive care in the 1960s, mortality in very preterm and very low birthweight infants has been decreasing steadily. Consequently, interest in the outcome of surviving infants is growing. Restriction of health care resources has stressed the need for information concerning the effect of individual treatment components on mortality and morbidity. Concern about the quality in apparently normal survivors has been increasing as well. The current flood of papers on these subjects illustrates the interest in these issues. The first part of this paper reviews the methodology used in follow-up studies in the past decades. It aims at methodological problems that hamper comparison between studies and preclude unequivocal conclusions. New treatment techniques seldom were but should be evaluated by randomised trials. To monitor the combined effects of changing obstetric and neonatal techniques on perinatal outcome, studies in geographically defined populations are recommended using data from early pregnancy until at least preschool age. Comparability of outcomes could be enhanced by international agreement on standardisation of assessment methods and outcome measures. In the second part the results concerning gestational age- and birthweight-specific mortality, impairments and disabilities and the risk factors for such disorders are discussed. Increased survival of even the tiniest infants is clearly established. This increase in survival has not yet been accompanied by an apparent increase in major morbidity. However, many minor impairments are reported, occurring often in combination and predisposing these children to deviations of normal development. Important changes in the manifestation of brain damage appear to occur during development. These findings stress the importance of long-term follow-up studies.

Improving health status in extremely low birthweight children between two and five years

The 5-year outcome of 101 extremely low birthweight (ELBW, < 1000 g) children discharged from the Neonatal Intensive Care Unit was reported. Over this period, there were four post-discharge deaths. The neurodevelopmental impairment rate was 18% overall: cerebral palsy 7%, blindness 3%, deafness 3% and developmental delay 10%. Seventy-one percent of children were readmitted to hospital. The mean number of admissions was 2.4 per child and the mean duration of total hospital stay was 11.3 days per child in the 5-year period. A trend was observed in a reduction in the readmission rate and hospital days in the 2-5-year period compared to the period between discharge and 2 years, though the differences were not statistically significant. The most common reason for readmission was for surgical procedures, primarily aural ventilation tube insertion and tonsillectomy and adenoidectomy. Significant health problems included recurrent wheezing episodes, stridor and croup in the period up to 2 years and otitis media and tonsillitis between 2 and 5 years. There was some catch-up growth, especially in height, between 2 and 5 years. Children with < 800 g birthweight had similar rates of neurodevelopmental impairment and hospital readmission to those of 800-999 g birthweight. However, they experienced more otitis media and pneumonia, had more ear, nose and throat operations, and at 5 years of age, more were below the 3rd centile for weight. This study showed that the health status of ELBW children had improved between 2 and 5 years, but they continued to experience recurrent health problems and hospital readmissions which would have resulted in added financial and emotional burdens to their families.

Chronic lung disease in very low birthweight infants: a prospective population-based study

A prospective population-based study of chronic lung disease among all very low birthweight infants (birthweight 500-1499 g) born in New Zealand in 1986 is reported. Of 413 of these infants admitted to neonatal units, 355 (86%) survived to 28 days. An additional 50 infants were recorded as liveborn but died in the labour ward or other place of birth. Both observed survival and survival adjusted for birthweight, gestation and gender were significantly (P less than 0.05) better in larger centres. Oxygen requirement was assessed at 28 days of age, 36 weeks equivalent gestation and 84 days of age, when 38.6, 23.1 and 13.8% of infants, respectively, were being treated with oxygen. To examine the joint effects of predictor variables on oxygen requirement at each age, the data were analysed using multiple logistic regression methods. At 28 days, lower birthweight, shorter gestation, respiratory distress syndrome (all P less than 0.0001), and gender and hospital principally caring for the infant (both P less than 0.05) were significantly associated with treatment with oxygen. In comparison with other studies, New Zealand appears to have a relatively high rate of chronic lung disease. We speculate that a contributing factor may be the small size of some regional neonatal units.

Improvement of outcome for infants of birth weight under 1000 g. The Victorian Infant Collaborative Study Group

The two year outcome of extremely low birth-weight (ELBW) infants (birth weight 500 to 999 g), born in the state of Victoria over two distinct eras, 1979-80 and 1985-7, were compared. In the 1979-80 era, 25.4% of the ELBW infants survived to 2 years of age; only 12.5% of liveborn ELBW infants survived to 2 years with no neurological disabilities. In the 1979-80 era, ELBW infants born outside the level III centres in the state were significantly disadvantaged in both mortality and neurological morbidity. By 1985-7, the two year survival rate of ELBW infants rose significantly from 25.4% to 37.9%. By 1985-7, the proportion of ELBW infants who survived to 2 years free of neurological disabilities increased from 12.5% to 26.2%. Despite the improved survival, the absolute number of 2 year old children survivors with severe neurological disabilities remained constant at 8/year in both eras. By 1985-7, fewer ELBW infants were born outside the level III centres, their survival rate remained lower, but the severe neurological disability rate in survivors was no longer significantly higher. There has been a concomitant improvement in both survival and reduction in neurological morbidity.

Outcome to 8 years of infants less than 1000 g birthweight: relationship with neonatal ventilator and oxygen therapy

The study involved a cohort of 59 consecutive survivors with birthweights less than 1000 g, born between 1977 and 1980, to 8 years of age. The aim of the report was to determine if those survivors who had received more oxygen and ventilator therapy differed in their outcome compared with those who had received less oxygen and ventilation. Children were graded into four groups, characterized by decreasing durations of oxygen and ventilation. Children who had received less oxygen and ventilation were more likely to be below the third percentile for weight at 2, 5 and 8 years but the trends were significant only at 2 and 5 years (P = 0.006, P = 0.013 and P = 0.19 respectively). The rate of cerebral palsy was 8% at 8 years; the only children with severe or moderate disabilities from their cerebral palsy were in the lowest oxygen and ventilation group (n = 4, P less than 0.02). The frequency of hospital re-admission and the duration of re-hospitalization did not vary significantly between the four groups at any age. The rates of recurrent wheezing episodes or asthma did not vary significantly between the groups. Although the cohort as a whole had some impairment of lung function compared with healthy full-term controls, there was no significant difference between the four groups. Contrary to expectations, our findings suggest lower rates of poor growth and adverse neurological outcomes with increasing durations of oxygen and ventilation in the newborn period.

Cognitive abilities and school performance of extremely low birth weight children and matched term control children at age 8 years: a regional study

The intellectual, psychoeducational, and functional status of a regional cohort of extremely low birth weight (ELBW) survivors who weighed 501 to 1000 gm at birth (n = 143) and who were born between 1977 and 1981 was compared with that of control children born at term (n = 145) who were matched for gender, age, and social class. One hundred twenty-nine ELBW survivors (90%) were available; their mean birth weight was 839 +/- 124 gm and mean gestational age 27 +/- 2.1 weeks, and 48 of them weighed less than or equal to 800 gm at birth. Both ELBW and control groups were tested at a mean unadjusted age of 8 years; 113 of 129 ELBW children completed the full test battery, eight blind children had other tests, and eight were not testable. The mean Full Scale IQ (Wechsler Intelligence Scale for Children--Revised) was 91 +/- 16 for ELBW children and 104 +/- 12 for control children (p less than 0.0001). Between 8% and 12% of the ELBW group scored in the "abnormal" range (less than or equal to -2 SD) on the Wechsler IQ and subtests, compared with 1% to 2% of the control group. The ELBW group did less well on the reading, spelling, and mathematics tests (Wide Range Achievement Test--Revised less than or equal to -2 SD: ELBW = 20% to 28%; control = 3% to 10%). The motor performance of the ELBW group (Bruininks-Oseretsky Test of Motor Proficiency less than or equal to -2 SD: ELBW = 20%; control = 1%) and their visual-motor integration (Beery Developmental Test of Visual-Motor Integration less than or equal to -2 SD: ELBW = 21%; control = 6%) were also poorer. Exclusion of 19 ELBW children with neurologic impairments or an IQ less than or equal to 70 or both did not result in significant improvement in Wechsler or achievement measures. Approximately 15% of the ELBW cohort performed in the abnormal range on the Vineland Adaptive Behavior Scales, compared with none of the control group. Although approximately two thirds of the ELBW group were performing in the normal range on intellectual measures, comparison with the control group suggests that, as a group, ELBW children were significantly disadvantaged on every measure tested.

Ocular defects in infants of extremely low birth weight and low gestational age

The eyes of 49 babies who weighed less than 1,000 g at birth or who were born at or before 28 weeks gestation were examined at the age of 4 years. Twenty-one children were normal. The remaining 29 children (59%) had ocular abnormalities which ranged from mild amblyopia to blindness from retinopathy of prematurity. The need to examine children at risk is stressed.

Improved outcome for infants weighting less than 750 grams at birth: effects of advances in perinatal care, infection prevention and maternal transport for fetus

Between 1980 and 1987, we investigated the outcome for 20 infants with birth weights less than 750 g, admitted to the neonatal unit of Kyushu University Hospital. All infants were delivered at the hospital. Seven infants (35%) survived and were discharged. Comparing the first and second 4 year periods, the survival rate improved from 17% (1 of 6 infants) to 43% (6 of 14 infants). Intensive perinatal care, prevention of infection and early transport of mothers of high-risk babies improved the outcome. In the long-term, among the 7 survivors, 1 had psychomotor retardation, 1 had epilepsy and the other 5 were normal neurologically. Growth in height and weight of these children remained below the -2SD levels until 2 years of age, thereafter they began to catch up. Growth in head circumference increased to a level above the -2SD value from 2 years of age. With intensive perinatal care, the outcome for infants weighting less than 750 g is improving, and good results may be expected.

Peak inspiratory pressure requirements in infants born weighing less than 750 g

The possibility that peak inspiratory pressure requirements or the arterial:alveolar oxygen ratio can predict the clinical outcome in infants weighing less than 750 g at birth was explored in a consecutive series. Nine of 10 infants (90%) with a peak inspiratory pressure requirement of more than 18 cm H2O at 48 hours or more than 16 cm H2O at 72 hours from age subsequently died later of respiratory causes (defined as death after 72 hours of pulmonary interstitial emphysema, bronchopulmonary dysplasia, or cor pulmonale). Twenty of 21 remaining infants (95%) survived until discharge. Using these data a 95th centile for peak inspiratory pressure requirement during the first 72 hours of life was constructed. The potential value of this centile in predicting later death of respiratory causes was examined in a separate series. Twelve of 15 infants (80%) whose peak inspiratory pressure requirements remained below the 95th centile, or were not ventilated (n = 6), survived. In contrast, 11 of 12 (92%) infants whose requirements crossed the 95th centile died later of respiratory causes. The infants who died had more radiological changes and higher mean arterial carbon dioxide pressure than survivors suggesting that the severity of the initial lung disease rather than the way that ventilation was managed determined prognosis. Peak inspiratory pressure requirement was more useful than arterial:alveolar oxygen ratio in clearly distinguishing between survivors and infants who died later of respiratory causes.

Growth patterns of low birth weight preterm infants: a longitudinal analysis of a large, varied sample

To obtain growth data on a large sample of low birth weight preterm infants, we monitored 608 infants longitudinally in an eight-site collaborative program. Ninety-nine infants weighed less than or equal to 1250 gm at birth, 289 between 1250 and 2000 gm, and 220 infants between 2000 and 2500 gm. Thirty-four percent were white, 52% black, and 14% Hispanic. Weight, height, and head circumference were measured at birth and at 40 weeks and 4, 8, and 12 months of gestation-corrected age on at least 553 infants each time. Descriptive statistics for all growth variables and a body mass index (kilograms per square meter), plotted by sex and birth weight group, demonstrated growth patterns lower than published standards for term infants of the same age and sex. These patterns of growth differed by birth weight group. No catch-up growth was noted by the 12-month examination (gestation-corrected age) for any birth weight group. We conclude that low birth weight preterm infants have different patterns of growth than term infants during the first year of life, even with plotting corrected for gestational age.

Survival and outcome of infants weighing less than 800 grams at birth

This study reports on two aspects of outcome in a sample of infants whose birth weights ranged from 500 to 799 gm. First, maternal and early neonatal variables were analyzed by means of stepwise logistic regression. Five-minute Apgar score and initial pH were the only variables that predicted mortality at p less than or equal to 0.05. Second, the surviving infants were examined at ages ranging from 17 months to 7 years. The majority (72%) had neurologic and/or developmental examinations in the suspect or abnormal range and required rehabilitation or early intervention services.