Prediction of outcome at school entry in neonatal intensive care unit survivors, with use of clinical and electrophysiologic techniques

NCS Assessments of the Motor, Sensory, and Physical Health Domains

As part of the National Children's Study (NCS) comprehensive and longitudinal assessment of the health status of the whole child, scientific teams were convened to recommend assessment measures for the NCS. This manuscript documents the work of three scientific teams who focused on the motor, sensory, or the physical health aspects of this assessment. Each domain team offered a value proposition for the importance of their domain to the health outcomes of the developing infant and child. Constructs within each domain were identified and measures of these constructs proposed. Where available extant assessments were identified. Those constructs that were in need of revised or new assessment instruments were identified and described. Recommendations also were made for the age when the assessments should take place.

Postnatal functional status of the brainstem auditory pathway in term infants after perinatal hypoxia-ischemia

OBJECTIVES

To examine postnatal changes in the impaired brainstem auditory pathway in term infants after perinatal hypoxia-ischemia (HI).

METHODS

Brainstem auditory evoked response (BAER) was studied at 2-4 months of age in term infants who suffered perinatal HI. The BAER data obtained at various click rates in these infants were compared with those in age-matched normal term controls to detect any abnormalities.

RESULTS

The infants after HI showed a slight elevation in BAER threshold. Four (9.8%) infants had threshold elevation. At 21/s clicks, there was a slight decrease in wave I latency, and a slight increase in wave III and V latencies. However, the I-V and I-III intervals in these infants were significantly increased (p < .05 and .05), whereas III-V interval was slightly increased. At higher click rates of 51 and 91/s, all BAER variables showed similar changes, with only small variations. An abnormal increase in the I-V and/or I-III intervals was seen in 4 (9.8%) infants, who were not associated with BAER threshold elevation.

CONCLUSIONS

At 2-4 months of age, around 20% of the infants after perinatal HI showed a moderate degree of either peripheral or central impairment of the brainstem auditor pathway. Monitoring postnatal changes could provide valuable information for postnatal care of infants after perinatal HI.

Bilateral loss of cortical SEPs predict severe MRI lesions in neonatal hypoxic ischemic encephalopathy treated with hypothermia

OBJECTIVE

The introduction of therapeutic hypothermia for neonatal hypoxic-ischemic encephalopathy calls for reevaluation of the prognostic role of somatosensory evoked potentials (SEPs).

METHODS

Among 80 consecutive neonates undergoing hypothermia for hypoxic-ischemic encephalopathy, 58 performed SEPs and MRI at 4-14 days of life and were recruited in this multicenter study. SEPs were scored as: 0 (bilaterally/unilaterally recorded N20) or 1 (bilaterally absent N20). The severity of brain injury was scored using MRI.

RESULTS

Bilaterally absent N20 was observed in 10/58 neonates (17%); all had moderate/severe MRI abnormalities; 36/48 neonates (75%) with score 0 at SEPs had normal MRI. The positive predictive value of SEPs on MRI outcome was of 1.00, while the negative predictive value 0.72, sensitivity 0.48, specificity 1.00, with an accuracy of 0.78 (p < .001).

CONCLUSIONS

Bilateral absence of cortical SEPs predicts moderate/severe MRI pattern of injury.

SIGNIFICANCE

Therapeutic hypothermia does not seem to significantly affect prognostic reliability of SEPs.

Auditory neural myelination is associated with early childhood language development in premature infants

BACKGROUND

Auditory neural myelination (ANM) as evaluated by auditory brainstem evoked response (ABR) during the neonatal period has been used as a surrogate outcome for long-term neurodevelopment. The validity of ANM as a surrogate outcome for long-term neurodevelopment has not been well studied.

AIM

Evaluate the association of ABR I-V interpeak latency (IPL), an index of ANM, at 35 week postmenstrual age (PMA) with language outcome at 3 years of age.

DESIGN

Prospective study.

SUBJECTS

24-33 week gestational age (GA) infants were eligible if they did not meet exclusion criteria: craniofacial malformation, chromosomal disorders, deafness, auditory dys-synchrony, TORCH infection, or non-English speaking parents. Infants with malignancy, head injury, encephalopathy, meningitis, blindness, or who died or relocated were also excluded.

OUTCOME MEASURES

ABRs were performed at 35 week PMA using 80 dB nHL and I-V IPL (ms) measured. Auditory Comprehension (AC) and Expressive Communication (EC) were evaluated by a speech-language pathologist at 3 years of age using Preschool Language Scale.

RESULTS

Eighty infants were studied. The mean GA and birth weight of infants were 29.2 weeks and 1336 g, respectively. There was association of worse ear I-V IPL and better ear I-V IPL with AC (Coefficient-5.4, 95% CI: -9.8 to -0.9 and Coefficient-5.5, 95% CI: -10 to-0.9, respectively) and EC (Coefficient-5.6, 95% CI: -9.5 to-1.8 and Coefficient-6.7, 95% CI: -10.6 to-2.7, respectively) after controlling for confounders.

CONCLUSION

The neonatal I-V IPL is a predictor of language development at 3 years of age in preterms.

Amplitude reduction in brainstem auditory response in term infants under neonatal intensive care

OBJECTIVE

To examine brainstem auditory electrophysiology in term neonates under intensive care due to perinatal conditions other than hypoxia-ischemia.

METHODS

Maximum length sequence brainstem auditory evoked response was studied in term neonates in an intensive care unit. The amplitudes of wave components of the response were analysed to assess brainstem auditory electrophysiology.

RESULTS

The amplitudes of all wave components in the neonates under intensive care tended to be smaller than in those in normal term controls. Wave I amplitude was significantly reduced at all 91-910/s clicks (p < 0.05-0.01). The amplitudes of waves III and V were also reduced, respectively, at 227-910/s (all p < 0.05) and at 455 and 910/s (both p < 0.01). The amplitude reduction was slightly more significant at higher than lower click rates, but there were no significant differences in the slopes of wave I, III and V amplitude-rate functions between the neonates under intensive care and the controls.

CONCLUSIONS

Wave amplitudes of maximum length sequence brainstem auditory evoked response were reduced in term neonates under intensive care due to perinatal conditions other than hypoxia-ischemia.

SIGNIFICANCE

Brainstem auditory electrophysiology is depressed in term neonates under intensive care, possibly due to collective adverse effects of perinatal conditions. The impairment to the neonatal, particularly rostral, brainstem due to other perinatal conditions is less severe than that due to hypoxia-ischemia previously reported.

Early neurophysiology and MRI in predicting neurological outcome at 9-10 years after birth asphyxia

OBJECTIVE

To assess whether early somatosensory evoked potentials (SEP) predict long-term neurodevelopmental outcome in normothermic, full-term infants with mild to moderate neonatal encephalopathy (NE), and to compare their predictive value to already available amplitude integrated EEG (aEEG) and magnetic resonance imaging (MRI).

METHODS

Fifty-six infants with post-asphyxia NE were prospectively recruited, and their SEP, aEEG and MRI data were acquired during the first five days. Follow-up continued to 9-10 years for assessment of neuromotor and neurocognitive development. We analysed SEP latency (N1 component), normality of aEEG background pattern, as well as patterns of injury on the neonatal MRI. Neurological outcome measures at 9-10 years included conventional MRI, Movement-ABC and the WISC-III NL.

RESULTS

A SEP latency <50 ms during the first five days was associated with a normal neuromotor outcome (p < 0.03), and a prolonged day 3 latency was associated with lower childhood IQ (p = 0.02). The presence of multiple seizures in aEEG, as well as a moderate or severe injury on the neonatal MRI was associated with a poor neuromotor score (p = 0.03 and p < 0.01, respectively). Combination of multiple techniques improved prediction of long-term outcome compared to single modality.

CONCLUSION

Early SEPs provide information that is comparable to the already available aEEG and MRI paradigms in the prediction of long-term outcome of full-term infants with mild to moderate neonatal encephalopathy.

SIGNIFICANCE

The present results call for further studies using early SEP to aid early assessment of infants treated with hypothermia.

Brainstem auditory response findings in term neonates in intensive care unit

OBJECTIVES

Whether term infants in neonatal intensive care unit (NICU) have brainstem auditory abnormalities remains to be determined. This study aimed to detect any abnormality in brainstem auditory function in term neonates who are admitted to NICU.

METHODS

From a NICU, we recruited 55 term neonates with various perinatal problems. They were studied during the first week after birth using brainstem auditory evoked response (BAER), and the results were compared with normal term controls.

RESULTS

Wave I and III latencies and I-III interpeak interval of the evoked response in the NICU term neonates were similar to those in the controls. Wave V latency and I-V and III-V interpeak intervals tended to be increased at 21/s clicks. The increase was more obvious at higher rates 51 and 91/s. Analysis of variance revealed that at 21/s clicks only III-V interval was significantly increased (p < 0.05). At 51 and 91/s clicks, wave V latency and III-V and I-V intervals were significantly increased (p < 0.05-0.01). The rates of the abnormalities were seen more at higher than at lower click rates. The amplitudes of waves I, III, and V in the NICU neonates were all slightly reduced, but none differed significantly from the controls.

CONCLUSIONS

There are some abnormalities in BAER in term neonates in NICU, suggesting functional abnormality in the auditory brainstem in NICU infants.

Neurodevelopmental outcomes in very low-birth-weight infants in Korea: 1998-2007 vs 1989-1997

The authors reviewed the medical records of very low-birth-weight infants admitted from 1998 to 2007 and compared neurodevelopmental outcomes with their previously reported data from 1989 to 1997. The recent group included 824 infants, and the previous group included 471 infants. Neurodevelopmental outcomes were classified into cerebral palsy and non-cerebral palsy neurodevelopmental impairment. In the recent group, the survival rate was significantly higher (79.4% vs 66.2%), the rate of cerebral palsy was lower (7.9% vs 10.5%), and the rate of non-cerebral palsy neurodevelopmental impairment was higher (6.0% vs 4.5%) but not significant. The survival rate increased significantly over time, but there was no significant change in neurodevelopmental outcomes over time. Multivariate analysis indicated that abnormal neurosonographic findings, using assisted ventilation, vaginal delivery, and abnormal brainstem auditory evoked potential, were associated with increased risk for cerebral palsy.

Neonatal somatosensory evoked potentials: maturational aspects and prognostic value

The aim of this prospective study was to evaluate the diagnostic role of somatosensory evoked potentials (SEP) during the neonatal period with regard to maturational changes and prognostic value in perinatal hypoxic-ischemic encephalopathy. Median nerve SEP analysis was performed in 31 healthy infants (group A1, 33-35 weeks, n = 10; group A2, 36-37 weeks, n = 11; group A3, 38-41 weeks, n = 10) and in 10 term infants with hypoxic-ischemic encephalopathy (group B). Cortical latency N1 and central conduction time values were analyzed for group A in relation to postconceptional age and postnatal age and for group B in relation to degree of hypoxic-ischemic encephalopathy and neurodevelopmental outcome (at the mean age of 6.6 + or - 1.6 years). Central latencies were correlated with postconceptional age but not postnatal age. Mean N1 latency and central conduction time values did not differ significantly between groups A1 and A2; the most pronounced decrease was between groups A2 and A3 (postconceptional ages 36-37 vs 38-41 weeks). In group B, central latencies were prolonged, compared with controls (P < 0.001), but were not significantly correlated with long-term outcome in patients with moderate hypoxic-ischemic encephalopathy (n = 6). Neonatal SEP analysis thus is an objective and noninvasive method for assessing functional integrity of the somatosensory pathway. In term infants, SEPs are a valuable additional tool for early diagnosis of hypoxic-ischemic encephalopathy, but are not prognostic of neurodevelopmental long-term outcome in moderate hypoxic-ischemic encephalopathy.

Concurrent validity of the Neurobehavioural Assessment for Pre-term Infants (NAPI) at term age

BACKGROUND

Accurate measurement of neonatal neurological integrity is critical for early identification of pre-term and full-term infants at-risk for developmental disability. The Neurobehavioural Assessment for Pre-term Infants (NAPI) was developed to measure the progression of neurobehavioural development in pre-term infants born between 32 weeks post-conceptional age (PCA) and term. This instrument has many unique advantages; however, criterion validity is unknown and results are subsequently difficult to interpret.

OBJECTIVES

This study examined the concurrent validity of the NAPI against a criterion instrument, the Einstein Neonatal Neurobehavioural Assessment Scale (ENNAS), which measures similar constructs and has demonstrated excellent reliability and validity.

METHODS

A sample of 41 pre-term and full-term infants (40 +/- 2 weeks) was assessed with the NAPI and ENNAS on the same day.

RESULTS

The findings demonstrated that correlations between similar NAPI clusters and ENNAS clusters ranged from 0.35-0.65 and correlations between many similar individual NAPI and ENNAS items ranged from 0.40-0.60. Two NAPI clusters also discriminated between normal, abnormal and suspect performance on the ENNAS.

CONCLUSION

The NAPI has many unique advantages as a tool. It examines neonates serially, has established weekly normative data and requires minimal infant handling. This study provides new validation of the NAPI instrument.

Ethics in neonatal neurology: when is enough, enough?

Decision-making for the severely neurologically compromised newborn is fraught with considerable medical and ethical difficulties. Multiple intrinsic and extrinsic factors challenge our prognostic certainty, which then challenges our ability both to communicate and to make decisions that are rooted in basic principles of fairness and moral integrity. Clinical vignettes illustrate the difficulties and highlight the present status regarding prognostication and consideration of general ethical principles that would permit the consensual withdrawal of care (i.e., end-of-life decisions). Futility in the neonatal setting is examined, as well the mechanisms of the decision-making process and existing relevant professional guidelines.

Brainstem auditory outcomes and correlation with neurodevelopment after perinatal asphyxia

We used brainstem auditory-evoked responses and neurodevelopmental assessment to detect abnormalities and correlations between such responses and neurodevelopmental outcomes in 78 children (aged 4-12 years) who survived perinatal asphyxia. Twenty children had brainstem auditory-evoked response abnormalities, including increased threshold, reduced wave V amplitude, decreased V/I amplitude ratio, and prolonged I-V interval. Thirty-seven exhibited neurodevelopmental deficits, including cerebral palsy and developmental delay. The remaining 41 exhibited no deficits. Brainstem auditory-evoked response abnormalities were evident in 15 of 37 (40.5%) children with neurodevelopmental deficits, but in only 5 of 41 (12.2%) with no deficits, which differed significantly (chi(2) = 8.2, P < 0.05). The sensitivity, specificity, positive predictive value, and false-negative rate of brainstem auditory-evoked responses to reflect neurodevelopmental outcomes were 40.5%, 87.8%, 75.0%, and 59.5%, respectively. These findings suggest that in children who survive perinatal asphyxia, brainstem auditory impairment occurs more frequently in those with versus those without neurodevelopmental deficits. Brainstem auditory-evoked responses display a moderate correlation with clinically determined neurodevelopmental outcomes. Despite limitations, brainstem auditory-evoked response is valuable for assessing auditory and neurodevelopmental outcomes after perinatal asphyxia.

Neonatal SEP - back to bedside with basic science

Scalp-recorded somatosensory evoked potentials (SEPs) have been successfully used in neonatal assessment for several decades. The current routine SEP paradigm is markedly predictive for future cerebral palsy (CP) or other neurocognitive sequelae in brain-injured babies. Recent advances in basic science have dramatically increased our knowledge about structural-functional development of SEP-related brain mechanisms. It has thereby become apparent that preterm SEP differs from that in more mature counterparts in that it also comprises responses from transient brain structures, and hence being unique to the preterm period. It is now obvious also that several aspects in the current SEP paradigm, ranging from the type of stimulation to the methods of recording and analysis, are suboptimal for preterm babies. Recent progress in recording and analysis techniques have made it possible to combine SEP studies with EEG recordings, as well as to implement advanced analyses (e.g. time-frequency analysis) into routine practice. This review summarizes literature from relevant areas in basic science, and proposes a novel, integrated approach in neonatal SEP studies in order to significantly increase the fidelity of testing somatosensory system.

A comparison of developmental assessments of the newborn and young infant

Neonatal neurobehavioral assessments describe a newborn's spontaneous behavioural repertoire and observable responses to environmental stimuli. Infant developmental assessments document the range of developmental skills that emerge and develop over the first years of life. This review highlights two neonatal assessments (Einstein Neonatal Neurobehavioral Assessment Scale, Neurobehavioral Assessment of the Preterm Infant) and two infant assessments (Alberta Infant Motor Scale, Test of Infant Motor Performance). A general description of these tests is followed by their content and psychometric properties. These standardized tests of neurologic integrity are useful in characterizing current developmental status and in monitoring change in performance over time.

Brain-stem auditory impairment during the neonatal period in term infants after asphyxia: dynamic changes in brain-stem auditory evoked response to clicks of different rates

OBJECTIVE

To explore dynamic changes in brain-stem auditory electrophysiology during the neonatal period in term infants after perinatal asphyxia.

METHODS

Sixty-eight term newborn infants who suffered asphyxia were studied on days 1, 3, 5, 7, 14 and 30 after birth. Brain-stem auditory evoked response (BAER) was recorded with clicks, delivered at 21, 51 and 91 s(-1) and > or =40 dB above BAER threshold of each subject.

RESULTS

During the neonatal period wave I latency in the infants after asphyxia increased slightly while later BAER components changed more significantly. On the first day after birth wave III and V latencies and I-V and III-V intervals increased significantly at all rates of clicks (ANOVA P<0.01-0.001). On day 3, the latencies and intervals increased further. III-V/I-III interval ratio increased at 51 and 91 s(-1), suggesting a relatively more significant increase in III-V interval than in I-III interval at higher rates. Thereafter, wave III and V latencies and all intervals decreased progressively, although these BAER variables were still significantly longer than in normal controls on days 5 and 7 (P<0.05-0.001) On day 30, all latencies and intervals approached near normal values, with a slight increase in wave V latency and I-V and III-V intervals at 51 and 91 s(-1).

CONCLUSIONS

Perinatal asphyxia has a major effect on central auditory function, resulting in acute impairment. The impairment progresses during the first 3 days and then tends towards recovery. By 1 month the impaired auditory function has largely returned to normal. Significant increase in click rates can moderately improve the detection of auditory impairment.

SIGNIFICANCE

After perinatal asphyxia early detection of hypoxic-ischaemic damage to the central auditory system and initialisation of neuroprotective and therapeutic measures during the first hours after birth are critical to prevent or reduce deterioration of central impairment.

Autoregulation of cerebral blood flow in fetuses with congenital heart disease: the brain sparing effect

Fetuses with congenital heart disease (CHD) have circulatory abnormalities that may compromise cerebral oxygen delivery. We believe that some CHD fetuses with decreased cerebral oxygen supply have autoregulation of blood flow that enhances cerebral perfusion (brain sparing). We hypothesize that cerebral autoregulation occurs in CHD fetuses, and the degree of autoregulation is dependent on the specific CHD and correlates with intrauterine head circumferences. CHD fetuses were compared to normal fetuses. Data included cardiac diagnosis, cerebral and umbilical artery Doppler, head circumference, weight, and gestational age. The cerebral-to-placental resistance ratio (CPR) was assessed as a measure of cerebral autoregulation. CPR = cerebral/umbilical resistance index (RI) and RI = systolic-diastolic/systolic velocity (normal CPR > 1). CPR > 1 was found in 95% of normal vs 44% of CHD fetuses. The incidence of CPR < 1 was greatest in hypoplastic left or right heart fetuses. Compared to normal, cerebral RI was decreased in CHD fetuses. The CPR vs gestational age relationship, and the relationship among weight, head circumference, and CPR differed across normal and CHD fetuses. Fetuses > 2 kg with CHD and a CPR < 1 had smaller head circumferences than normal. Brain sparing occurs in CHD fetuses. Fetuses with single ventricular physiology are most affected. Inadequate cerebral flow in CHD fetuses, despite autoregulation, may alter brain growth.

Prediction of outcome at school age in neonatal intensive care unit graduates using neonatal neurologic tools

Prediction of outcome for neonatal intensive care unit graduates is clinically useful to counsel families effectively and target those who may benefit from early interventions. Evoked potentials have proven prognostic value of neurologic outcomes in early childhood; however, their long-term predictive validity remains to be determined. The objective of this prospective study was to determine the long-term predictive value of three neonatal neurologic assessments: brainstem auditory evoked potentials, somatosensory evoked potentials, and the Einstein Neonatal Neurobehavioral Assessment Scale. Seventy-eight high-risk newborns and 28 healthy controls were recruited and were assessed in the newborn period using these tests. At 8 to 9 years of age, 42 subjects and 13 controls were re-evaluated for developmental progress using a range of psychologic, sensorimotor, and neurologic measures. Findings indicated that the somatosensory evoked potential was most accurate at predicting outcome at school age, with high specificity (83-100%) across all domains tested and good sensitivity (80-100%) for intellectual performance and sensorimotor abilities. The brainstem auditory evoked potential was limited by false-negatives, whereas the neonatal neurobehavioral assessment yielded many false-positives. This study provides new evidence that associations between neonatal somatosensory evoked potentials and developmental sequelae continue to be significant at school age.

Neonatal neurologic prognostication: the asphyxiated term newborn

The pediatric neurologist is often requested to predict the neurologic outcome in an uncertain situation. A common and problematic clinical setting in which this occurs is the asphyxiated term newborn. This report reviews the predictive tools available for prognostication in this situation and formulates a practical paradigm that the authors hope will improve predictive accuracy and lessen uncertainty in this setting.

Multimodality evoked potential findings in infants with congenital heart defects

Evoked potentials are sensitive prognostic tools in young infants at risk for developmental disability. The objective of this prospective study was to determine whether infants with congenital heart defects demonstrate evoked potential abnormalities prior to or following open heart surgery, and to examine the association between these abnormalities and developmental status 1 year following surgery. A consecutive series of newborns (less than 1 month old) and infants (1 month to 2 years old) were recruited. Somatosensory and brain stem auditory evoked potentials were carried out before or after cardiac surgery, or both. One year later, neurologic examination and standardized measures of motor performance and functional independence were carried out. Twenty-seven newborns and 31 infants underwent perioperative somatosensory evoked potential recordings. Results indicate that perioperative somatosensory evoked potential abnormalities were common in newborns (41%) but not in infants (13%) with congenital heart defects. Brainstem conduction times were within normal limits in all subjects; however, 32% presented with mild elevations in hearing thresholds. All newborns with abnormal somatosensory evoked potentials had abnormal neurologic examinations both perioperatively and again 1 year after open heart surgery. Moreover, standardized developmental assessments 1 year following surgery indicate that all newborns with somatosensory evoked potential abnormalities had developmental deficits in one or more domains. Somatosensory evoked potential abnormalities in the perioperative period are common in newborns with congenital heart defects, and are strongly predictive of persistent developmental delay later.

Educational disabilities of neonatal intensive care graduates

OBJECTIVE

To determine the relationship between perinatal and sociodemographic factors in low birth weight and sick infants hospitalized at regional neonatal intensive care units (NICUs) and subsequent educational disabilities.

METHOD

NICU graduates born between 1980 and 1987 at nine statewide regionalized level III centers were located in Florida elementary schools (kindergarten through third grade) during academic year 1992-1993 (n = 9943). Educational disability was operationalized as placement into eight mutually exclusive types of special education (SE) classifications determined by statewide standardized eligibility criteria: physically impaired, sensory impaired (SI), profoundly mentally handicapped, trainable mentally handicapped, educable mentally handicapped, specific learning disabilities, emotionally handicapped, and speech and language impaired (SLI). Logistic regression was used to estimate the odds of placement in SE for selected perinatal and sociodemographic variables.

RESULTS

Placement into SE ranged from .8% for SI to 9.9% for SLI. Placement was related to four perinatal factors (birth weight, transport, medical conditions [congenital anomalies, seizures or intraventricular hemorrhage] and ventilation), and five sociodemographic factors (child's sex, mother's marital status, mother's race, mother's educational level, and family income). Perinatal factors primarily were associated with placement in physically impaired, SI, profoundly mentally handicapped, and trainable mentally handicapped. Perinatal and sociodemographic factors both were associated with placement in educable mentally handicapped and specific learning disabilities whereas sociodemographic factors primarily were associated with placement in emotionally handicapped and SLI.

CONCLUSIONS

Educational disabilities of NICU graduates are influenced differently by perinatal and sociodemographic variables. Researchers must take into account both sets of these variables to ascertain the long-term risk of educational disability for NICU graduates. Birth weight alone should not be used to assess NICU morbidity outcomes.

Multimodality evoked potentials as a prognostic tool in term asphyxiated newborns

Hypoxic-ischemic (HI) events may cause permanent brain damage, and it is difficult to predict the long-term neurological outcome of survivors. Multimodality evoked potentials (MEPs), using flash visual (fVEPs), somatosensory (SEPs), and brain-stem auditory evoked potentials (BAEPs) may assess the cerebral function in term neonates. MEPs were recorded in 40 hypoxic-ischemic term or near-term neonates during the first week of life in order to predict the neurological outcome. A 3 point grading system registered either mild, moderate, or severe abnormalities. At 24 months of corrected age, the infants were assessed with a blind protocol to determine neurological development. Grade 0 fVEPs and SEPs were associated with a normal neurological status with 100% (P < 0.001) of the infants. Abnormal SEPs or total grade (VEPs + SEPs) > I were not associated with normal outcomes (P < 0.0001). Normal BAEPs did not predict a normal outcome, but severely abnormal BAEPs did predict an abnormal outcome. A significant correlation was found between EP (VEPs + SEPs) grade (r = 0.9, P < 0.0001), Sarnat stage (r = 0.6, P < 0.001), and clinical outcome. This study confirmed that both fVEPs and SEPs are more accurate as prognostic indicators for term neonates. EPs (VEPs + SEPs) also are more accurate in predicting the ultimate neurological outcome compared with the Sarnat scoring.

Agreement between the neonatal neurological examination and a standardized assessment of neurobehavioural performance in a group of high-risk newborns

The degree of agreement between the neonatal neurological examination and a standardized neurobehavioural assessment was investigated in a group of 32 newborns with congenital heart defects. A paediatric neurologist performed a neurological examination, and an occupational therapist administered the Einstein Neonatal Neurobehavioural Assessment Scale on all subjects. Both examiners independently evaluated each subject, and were blinded to the diagnosis, to perinatal status and to each other's clinical findings. Statistical analysis demonstrated a significant association between the overall impression between both examiners (p < .0001), with a crude agreement of 96.9%. Sixteen neonates were determined to be normal and 15 abnormal by both examiners, with disagreement in only one subject. Although two distinct approaches were employed in the neurological assessment of high-risk newborns, both assessments evaluate the maturity and integrity of the immature central nervous system. The results demonstrate a strong agreement between these two approaches, suggesting that the neonatal neurological examination is consistent and valid.

Evoked potentials as predictors of outcome in neonatal intensive care unit survivors: review of the literature

Neonatal intensive care unit survivors are at substantial risk for a range of neurodevelopmental sequelae, and therefore a variety of clinical diagnostic techniques have been evaluated as predictors of outcome. We summarize the prognostic value of evoked potentials in newborns at risk. A review of the literature reveals that brainstem conduction abnormalities in auditory brainstem evoked potentials are associated with neuromotor impairment; however, there are many false negative studies. Visual evoked potentials are highly accurate in predicting neurologic deficits in early childhood in asphyxiated term neonates. Sensitivity and specificity are consistently high for somatosensory evoked potentials in term newborns; however, correlations with outcome in premature infants is controversial. Several studies have compared neonatal findings on neuroimaging studies and evoked potentials, and concordant results between these two tests are highly predictive. However, neurologic sequelae often can most accurately be predicted by visual or somatosensory evoked potentials. Evoked potentials may therefore be a useful adjunct to the clinical investigation and prognostication of outcome in the high risk newborn.