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

Clinical utility and psychometric properties of tools for early detection of developmental concerns and disability in young children: A scoping review

AIM

To explore the clinical utility and psychometric properties of standardized tools for the early detection of developmental concerns or disability in young children.

METHOD

Systematic reviews and clinical practice guidelines containing psychometric data on tools appropriate for use with children from birth to 5 years 11 months were searched for in MEDLINE, CINAHL, Embase, and PsycINFO for the years 2000 to 2023, with no language restrictions.

RESULTS

Eighty-six systematic reviews and six clinical practice guidelines guided identification of tools. A total of 246 tools were identified across domains of neurological, motor, cognition, communication/language, social-emotional, sensory processing, and/or specific diagnostic conditions of attention-deficit/hyperactivity disorder, autism spectrum disorder, cerebral palsy, developmental coordination disorder, and fetal alcohol spectrum disorder. After critical evaluation, 67 tools were included in the recommendations. Recommendations for screening and diagnostic assessment tools were based on best available evidence for predictive and discriminative validity, diagnostic accuracy, together with consideration of resource use and accessibility.

INTERPRETATION

This comprehensive scoping review provides recommendations on the best tools for primary care, medical, allied health professionals, nursing, and other health workers to detect and identify developmental concerns or disability in young children using evidence-based tools.

Fluid restriction for term infants with hypoxic-ischemic encephalopathy following perinatal asphyxia-a randomized controlled trial

Fluid management in the first postnatal week among infants with perinatal asphyxia and hypoxic-ischemic encephalopathy (HIE) is an important knowledge gap. We aimed to evaluate the effects of fluid restriction on short- and long-term outcomes in infants with HIE. Term infants with moderate or severe HIE on therapeutic hypothermia were randomized within 6 hours of age to receive either restricted intravenous maintenance fluids (45 ml/kg/day on day 1 to a maximum of 120 ml/kg/day on day 6) vs conventional fluid (60 ml/kg/day on day 1 to a maximum of 150 ml/kg/day on day 6). The primary outcome was a composite of mortality or neurological abnormality at hospital discharge. We studied neurodevelopmental disability at 18-24 months using Bayley Scales of Infant Development, third edition. A total of 210 infants were randomized. Three infants died during the hospital stay. The primary outcome of mortality or neurological abnormality at discharge was not significantly different between the restricted and the conventional fluid group [57% vs 53%, RR: 1.07 (95% CI: 0.83, 1.37), P-value .58]. The incidence of cranial magnetic resonance imaging abnormalities was similar in the groups (65% vs 71%, P-value .30). There were no differences in the rates of severe neurodevelopmental disability at 18-24 months in the two groups [27% vs 28%, RR: 0.96 (95% CI: 0.62, 1.50), P-value .88]. Adverse outcomes were similar in both groups. Fluid restriction in the first postnatal week of life did not improve short- and long-term neurodevelopmental outcomes in term infants with moderate or severe HIE.

Predicting Adverse Neurodevelopmental Outcomes in Premature Neonates with Intrauterine Growth Restriction Using a Three-Layered Neural Network

Background/Objectives: There is a constant need to improve the prediction of adverse neurodevelopmental outcomes in growth-restricted neonates who were born prematurely. The aim of this retrospective study was to evaluate the predictive performance of a three-layered neural network for the prediction of adverse neurodevelopmental outcomes determined at two years of age by the Bayley Scales of Infant and Toddler Development, 3rd edition (Bayley-III) scale in prematurely born infants by affected by intrauterine growth restriction (IUGR). Methods: This observational retrospective study included premature newborns with or without IUGR admitted to a tertiary neonatal intensive care unit from Romania, between January 2018 and December 2022. The patients underwent assessment with the Amiel-Tison scale at discharge, and with the Bailey-3 scale at 3, 6, 12, 18, and 24 months of corrected age. Clinical and paraclinical data were used to construct a three-layered artificial neural network, and its predictive performance was assessed. Results: Our results indicated that this type of neural network exhibited moderate predictive performance in predicting mild forms of cognitive, motor, and language delays. However, the accuracy of predicting moderate and severe neurodevelopmental outcomes varied between moderate and low. Conclusions: Artificial neural networks can be useful tools for the prediction of several neurodevelopmental outcomes, and their predictive performance can be improved by including a large number of clinical and paraclinical parameters.

Central mechanisms of muscle tone regulation: implications for pain and performance

Muscle tone represents a foundational property of the motor system with the potential to impact musculoskeletal pain and motor performance. Muscle tone is involuntary, dynamically adaptive, interconnected across the body, sensitive to postural demands, and distinct from voluntary control. Research has historically focused on pathological tone, peripheral regulation, and contributions from passive tissues, without consideration of the neural regulation of active tone and its consequences, particularly for neurologically healthy individuals. Indeed, simplistic models based on the stretch reflex, which neglect the central regulation of tone, are still perpetuated today. Recent advances regarding tone are dispersed across different literatures, including animal physiology, pain science, motor control, neurology, and child development. This paper brings together diverse areas of research to construct a conceptual model of the neuroscience underlying active muscle tone. It highlights how multiple tonic drive networks tune the excitability of complex spinal feedback circuits in concert with various sources of sensory feedback and in relation to postural demands, gravity, and arousal levels. The paper also reveals how tonic muscle activity and excitability are disrupted in people with musculoskeletal pain and how tone disorders can lead to marked pain and motor impairment. The paper presents evidence that integrative somatic methods address the central regulation of tone and discusses potential mechanisms and implications for tone rehabilitation to improve pain and performance.

Postnatal levels of glycated albumin and glycated hemoglobin A1c in mothers of large-for-gestational-age newborns

Background

Gestational diabetes mellitus (GDM) is an important cause of macrosomia. The value of glycated albumin (GlyA) has been demonstrated to be a useful marker of glycemic control in pregnancy and a predictor of adverse perinatal outcomes. The aim of this study was to investigate the relationship between the postnatal levels of GlyA and glycated hemoglobin A1c (HbA1c) regarding the prenatal diagnosis of GDM in mothers of large-for-gestational-age (LGA) newborns.

Methods

The study included mothers and their LGA newborns born between July 2017 and September 2019. The mothers were grouped according to the prenatal diagnosis of GDM, and measurements of GlyA and HbA1c levels in their serum were performed on the first day after delivery of a LGA newborn.

Results

A total of 61 LGA newborns and their mothers were enrolled in the study. The median GlyA level was higher, at 16.4% (81.0 µmol/L), whereas the HbA1c level was lower in the group without a prenatal diagnosis of GDM; the differences between groups regarding the GlyA and HbA1c levels were not significant (p > 0.05). The postnatal level of maternal GlyA was positively correlated with birth weight (β = 0.022, p = 0.007), but no correlation with the presence of other adverse perinatal outcomes was found.

Conclusion

Mothers of LGA newborns who were not diagnosed with GDM during pregnancy had higher median levels of GlyA and lower HbA1c levels than mothers with prenatal diagnosis of GDM. Values of GlyA in mothers were positively correlated with the birth weight of their newborns but no correlation with other adverse perinatal outcomes was found. Our results indicate the potential value of GlyA for screening of GDM in the last trimester of pregnancy.

Does placental VEGF-A protein expression predict early neurological outcome of neonates from FGR complicated pregnancies?

OBJECTIVES

Fetal hypoxia due to placental dysfunction is the hallmark of fetal growth restriction (FGR). Preferential perfusion of the brain (brain-sparing effect), as a part of physiological placental cardiovascular compensatory mechanisms to hypoxia, in FGR was reported. Therefore, the correlation between vascular endothelial growth factor A (VEGF-A) protein expression in the FGR placentas and newborns' early neurological outcome was examined.

METHODS

This study included 50 women with FGR complicated pregnancies and 30 uneventful pregnancies. Fetal hemodynamic parameters, neonatal acid-base status after delivery, placental pathohistology and VEGF-A expression were followed. Early neonatal morphological brain evaluation by ultrasound and functional evaluation of neurological status by Amiel - Tison Neurological Assessment at Term (ATNAT) were performed.

RESULTS

VEGF-A protein expression level was significantly higher in the FGR placentas than normal term placentas (Fisher-Freeman-Halton's test, p≤0.001). No statistically significant correlation between placental VEGF-A expression and different prenatal and postnatal parameters was noticed. Whereas the alteration of an early neurological status assessed by ATNAT was found in 58 % of FGR newborns, morphological brain changes evaluated by UZV was noticed in 48 % of cases. No association between the level of placental VEGF-A expression and the early neurological deficits was found.

CONCLUSIONS

As far as we know this is the first study of a possible connection between VEGF-A protein expression in the FGR placentas and neonates' early neurological outcomes. The lack of correlation between the FGR placental VEGF-A expression and neonates' neurological outcome could indicate that optimal early neurodevelopment may take place due to compensatory mechanism not related to placental VEGF-A expression.

Neurological outcomes in neonates treated with therapeutic hypothermia: challenges in a developing country

BACKGROUND

 Hypoxic-ischemic encephalopathy (HIE) affects 1.5 newborns per 1 thousand term live births. Therapeutic hypothermia (TH) does not prevent all adverse outcomes. The experience with TH is still limited in Latin America. In Rio de Janeiro, Hospital Universitário Pedro Ernesto treats neonates with HIE since 2017 using the servo-controlled system.

OBJECTIVE

 To describe the frequency of epilepsy, altered neurological exam, and neurodevelopmental delay at 12 months of age in patients treated with TH in a reference hospital in Rio de Janeiro and to evaluate the possible risk associations with clinical data and data from complementary exams.

METHODS

 We evaluated medical records from the Neonatal Intensive Care Unit hospitalization and from first evaluation recorded at 12 months of age in the High-Risk Neonate Follow-up Outpatient Sevice.

RESULTS

 A total of 30 subjects were included in the study. We found epilepsy in 18.2% of the patients, altered neurological exam in 40.9%, and neurodevelopmental delay in 36.4%. We also found a significant relationship between altered magnetic resonance imaging scan and subsequent altered neurological exam. Our findings are in line with those of the international literature, which shows that adverse outcomes are still observed, even when TH is applied. Brazilian data shows our limited access to complementary exams. The rate of loss to follow-up was of 26.6%, probably due to the coronavirus disease 2019 (COVID-19) pandemic and to unfavorable socioeconomic conditions. More time for prospective follow-up and protocol adjustments should contribute to improve our data.

CONCLUSION

 High incidences of epilepsy, altered neurological exams, and neurodevelopmental delay were found, despite the use of TH. A more efficient use of resources is needed, as well as measures such as early intervention.

Exposure to Maternal Diabetes during Pregnancy Is Associated with Aggravated Short-Term Neonatal and Neurological Outcomes following Perinatal Hypoxic-Ischemic Encephalopathy

OBJECTIVE

Infants of diabetic mothers (IDM) are at higher risk of perinatal morbidities and glycemic instability, but the impact of maternal diabetes on neonatal and neurological short-term outcomes of neonates with hypoxic-ischemic encephalopathy (HIE) remains poorly described. Our objective was to determine the impact of maternal diabetes on neonatal and neurological short-term outcomes following neonatal HIE.

STUDY DESIGN

This was a retrospective single-center study including 102 term neonates with HIE who received therapeutic hypothermia (TH) treatment between 2013 and 2020. Multiple regression analysis was used to assess the relationship between the presence of maternal diabetes and short-term outcomes.

RESULTS

Neonates with HIE and maternal diabetes exposure had a significantly lower gestational age at birth (38.6 vs. 39.7 weeks of gestation, p = 0.005) and a significantly higher mean birth weight (3,588 ± 752 vs. 3,214 ± 514 g, p = 0.012). IDM with HIE were ventilated for longer duration (8 vs. 4 days, p = 0.0047) and had a longer neonatal intensive care unit (NICU) stay (18 vs. 11 days, p = 0.0483) as well as took longer time to reach full oral feed (15 vs. 7 days, p = 0.0432) compared with neonates of nondiabetic mother. Maternal diabetes was also associated with an increased risk of death or abnormal neurological examination at discharge in neonates with HIE (odds ratio: 6.41 [1.54-26.32]).

CONCLUSION

In neonates with HIE, maternal diabetes is associated with an increased risk of death or short-term neonatal morbidities, such as longer duration of ventilation, prolonged neonatal stay, greater need for tube feeding, and being discharged with an abnormal neurological examination. Strategies to prevent, reduce, or better control maternal diabetes during pregnancy should be prioritized to minimize complications after perinatal asphyxia.

KEY POINTS

· Maternal DB is associated with unfavorable outcomes.. · IDM have longer ventilatory support and tube feeding.. · IDM have higher risk of abnormal neurological examination..

Revolutionizing Neonatal Care: A Comprehensive Assessment of Neuromotor Development in At-Risk Infants Using the Novel Neonatal Infant Motor Assessment Scale (NIMAS) Test Battery

We developed a new neonatal neuromotor test battery, the Neonatal Infant Motor Assessment Scale (NIMAS), to perform a detailed neuromotor and holistic assessment of at-risk infants in the neonatal period.

METHODS

A total of 68 infants (28-41 Gestational weeks) hospitalised in the Neonatal Intensive Care Unit were included in the study. The NIMAS is a scale consisting of Automatic Motor Area, Functional Motor Area and sociodemographic form. The Dubowitz Neurological Examination and the Amiel-Tison Neurological Assessment Tests were also applied to evaluate the construct validity of the test.

RESULTS

The mean gestational age at birth was 34.62 ± 3.07 weeks and birth weight was 2305.66 ± 738.95. Fifty-one (75%) of the babies were premature and 17 (25%) were term babies. The KMO value to test the adequacy of the distribution for factor analysis was found to be at a very good level. Barlett's test result was 2198.389 (p < 0.05). The amount of variance obtained as 44.76% in the study was at a sufficient level. The factor loads of the questions in the automatic motor domain dimension varied between 0.523 and 0.694 and the factor loads of the questions in the functional motor domain dimension varied between 0.619 and 0.772. Since Cronbach's alpha was above 0.70, the reliability was adequate. Inter-rater scale agreement in the automatic motor domain was 81.1%; scale agreement in the functional motor domFain was 92.9%; and the NIMAS total score agreement was 93.4%. These agreements were statistically significant (p < 0.05). Total correlation above 0.20 indicates that the item is important for the question. According to the results obtained, total correlation values were between 0.258 and 0.720.

CONCLUSIONS

The NIMAS is the first test battery to assess the "Functional Motor Area" and this questionnaire, based on the results of the analyses, is a valid, reliable and clinically usable measurement tool for the infant at-risk at the neonatal period.

Serum Vitamin D status in full term neonates with severe perinatal depression

BACKGROUND

Severe perinatal depression is a significant cause of mortality and morbidity in neonates. Vitamin D levels were observed to be low in mothers and their neonates with hypoxic ischemic encephalopathy in some studies, owing to its neuroprotective properties.

OBJECTIVE

Primary objective was to compare vitamin D deficiency state in full term neonates with severe perinatal depression and healthy term controls. Secondary objectives were to determine sensitivity and specificity of serum 25(OH)D<12 ng/mL in predicting mortality, development of hypoxic ischemic encephalopathy, abnormal neurological examination at discharge, and developmental outcome at 12 weeks of age.

MATERIAL AND METHODS

Serum 25(OH)D levels in full term neonates with severe perinatal depression and healthy controls were compared.

RESULTS

Serum 25(OH)D levels in severe perinatal depression and controls (n = 55 each group) were significantly different (7.50 ± 3.53 ng/mL vs 20.23 ± 12.70 ng/mL). At cut-off of <  12 ng/mL, serum 25(OH)D could predict mortality with 100% sensitivity and 17% specificity and poor developmental outcomes with sensitivity of 100% and specificity of 50% .

CONCLUSION

Vitamin D deficiency status at birth can serve as an effective screening tool and poor prognostic markers in term neonates with severe perinatal depression.

Survival and Neurodevelopmental Outcome of Extremely-Low-Birth-Weight Infants at One Year of Age-A Prospective, Descriptive Study

OBJECTIVES

To study the survival rates at discharge and neurodevelopmental outcome at 1 y of corrected age (CA) of extremely-low-birth-weight ELBW neonates.

METHODS

This prospective, descriptive study was conducted in a tertiary care level III extramural NICU of a teaching hospital. Forty-nine extremely-low-birth-weight (ELBW) neonates were enrolled in the study from July 2017 to June 2018. Baseline demographic data, morbidities during NICU stay, and survival at discharge for the enrolled neonates were recorded. The enrolled infants were followed up to 1 y of CA at three-monthly intervals. During the follow-up, anthropometry, developmental screening by Denver Developmental Screening Test (DDST), and tone assessment by Amiel-Tison scale were done. Developmental Assessment Scale for Indian Infants (DASII) was administered at CA of 12 mo.

RESULTS

Thirty-seven (75.5%) neonates survived to discharge. Survival rate of neonates with birth weight > 750 g and with gestational age ≥ 26 wk was 90.2% and 85.7%, respectively. Amongst those < 750 g or < 26 wk (n = 8), none survived. Abnormal developmental quotient (DQ < 70%) was seen in 6 infants out of 33 infants (18.1%) followed at 1 y of CA.

CONCLUSION

Overall, 3/4^th of ELBW infants survived to discharge and 80% of those who were followed up at 1 y of CA had normal neurodevelopmental outcome. However, survival rates of neonates born at < 26 wk and/or with birth weight < 750 g  were less and needs to be improved.

Key role of Rho GTPases in motor disorders associated with neurodevelopmental pathologies

Growing evidence suggests that Rho GTPases and molecules involved in their signaling pathways play a major role in the development of the central nervous system (CNS). Whole exome sequencing (WES) and de novo examination of mutations, including SNP (Single Nucleotide Polymorphism) in genes coding for the molecules of their signaling cascade, has allowed the recent discovery of dominant autosomic mutations and duplication or deletion of candidates in the field of neurodevelopmental diseases (NDD). Epidemiological studies show that the co-occurrence of several of these neurological pathologies may indeed be the rule. The regulators of Rho GTPases have often been considered for cognitive diseases such as intellectual disability (ID) and autism. But, in a remarkable way, mild to severe motor symptoms are now reported in autism and other cognitive NDD. Although a more abundant litterature reports the involvement of Rho GTPases and signaling partners in cognitive development, molecular investigations on their roles in central nervous system (CNS) development or degenerative CNS pathologies also reveal their role in embryonic and perinatal motor wiring through axon guidance and later in synaptic plasticity. Thus, Rho family small GTPases have been revealed to play a key role in brain functions including learning and memory but their precise role in motor development and associated symptoms in NDD has been poorly scoped so far, despite increasing clinical data highlighting the links between cognition and motor development. Indeed, early impairements in fine or gross motor performance is often an associated feature of NDDs, which then impact social communication, cognition, emotion, and behavior. We review here recent insights derived from clinical developmental neurobiology in the field of Rho GTPases and NDD (autism spectrum related disorder (ASD), ID, schizophrenia, hypotonia, spastic paraplegia, bipolar disorder and dyslexia), with a specific focus on genetic alterations affecting Rho GTPases that are involved in motor circuit development.

The Effectiveness of Sensory Integration Interventions on Motor and Sensory Functions in Infants with Cortical Vision Impairment and Cerebral Palsy: A Single Blind Randomized Controlled Trial

Cortical vision impairment (CVI) and Cerebral Palsy (CP) lead to decrement in sensory and motor functions of infants. The current study examined the effectiveness of sensory integration interventions on sensory, motor, and oculomotor skills in infants with cortical vision impairment. Thirty-four infants with and CP aged 12−18 months were enrolled to the study. The infants were randomly divided into two groups as the control and intervention groups. The intervention group took sensory integration intervention 2 days a week for 8 weeks in addition to conventional physiotherapy 2 days a week for 8 weeks. The control group only received the conventional physiotherapy program 2 days a week for 8 weeks. The duration of the treatment sessions were 45 min for both interventions. Before and after the intervention, sensory processing functions were evaluated with the Test of Sensory Functions in Infants (TSFI), and motor functions were evaluated with the Alberta Infant Motor Scale (AIMS). There was a statistically significant difference between the pre- and post-test mean TSFI total and AIMS scores in the intervention group and control group (p < 0.001). The intervention group mean TSFI scores were more statistically significant than the those of the control group. Mean post-intervention AIMS scores did not differ between groups. Sensory integration intervention delivered with the conventional physiotherapy program was more effective than the conventional physiotherapy program in increasing sensory processing skills in one measure in infants with CVI and CP.

Neurodevelopmental outcome of Italian preterm ELBW infants: an eleven years single center cohort

BACKGROUND

Preterm extremely low birth weight infants (ELBWi) are known to be at greater risk of developing neuropsychiatric diseases. Identifying early predictors of outcome is essential to refer patients for early intervention. Few studies have investigated neurodevelopmental outcomes in Italian ELBWi. This study aims to describe neurodevelopmental outcome at 24 months of corrected age in an eleven-year single-center cohort of Italian ELBWi and to identify early risk factors for adverse neurodevelopmental outcomes.

METHODS

All infants born with birth weight < 1000 g and admitted to the Neonatal Intensive Care Unit of the "Fondazione IRCCS Policlinico San Matteo" hospital in Pavia, Italy, from Jan 1, 2005 to Dec 31, 2015 were eligible for inclusion. At 24 months, Griffiths' Mental Developmental Scales Extended Revised (GMDS-ER) were administered. Neurodevelopmental outcome was classified as: normal, minor sequelae (minor neurological signs, General Quotient between 76 and 87), major sequelae (cerebral palsy; General Quotient ≤ 75; severe sensory impairment). Univariate and multivariate multinomial logistic regression models were performed to analyze the correlation between neonatal variables and neurodevelopmental outcome.

RESULTS

176 ELBWi were enrolled (mean gestational age 26.52 weeks sd2.23; mean birthweight 777.45 g sd142.89). 67% showed a normal outcome at 24 months, 17% minor sequelae and 16% major sequelae (4.6% cerebral palsy on overall sample). The most frequent major sequela was cognitive impairment (8.52%). In the entire sample the median score on the Hearing-Speech subscale was lower than the median scores recorded on the other subscales and showed a significantly weaker correlation to each of the other subscales of the GMDS-ER. Severely abnormal cUS findings (RRR 10.22 p 0.043) and bronchopulmonary dysplasia (RRR 4.36 p 0.008) were independent risk factors for major sequelae and bronchopulmonary dysplasia for minor sequelae (RRR 3.00 p 0.018) on multivariate multinomial logistic regression.

CONCLUSIONS

This study showed an improvement in ELBWI survival rate without neurodevelopmental impairment at 24 months compared to previously reported international cohorts. Cognitive impairment was the most frequent major sequela. Median scores on GMDS-ER showed a peculiar developmental profile characterized by a selective deficit in the language domain. Severely abnormal cUS findings and bronchopulmonary dysplasia were confirmed as independent risk factors for major sequelae.

Effect of enteral zinc supplementation on growth and neurodevelopment of preterm infants: a systematic review and meta-analysis

OBJECTIVE

To evaluate effect of enteral zinc supplementation on growth and neurodevelopmental outcomes of preterm infants.

STUDY DESIGN

A systematic review and meta-analysis of randomized-controlled trials (RCTs) examining growth and neurodevelopmental outcomes after zinc supplementation in preterm infants.

RESULTS

Of eight RCTs involving 742 infants included, seven reported growth anthropometrics at 3-6 months corrected age (CA) and two reported neurodevelopmental outcomes at 6-12 months CA. Zinc supplementation was associated with increased weight z-score (weighted mean difference (WMD) = 0.50; 95% CI 0.23-0.76, heterogeneity I2 = 89.1%; P < 0.01), length z-score (WMD = 1.12; 95% CI 0.63-1.61, heterogeneity I2 = 96.0%; P < 0.01) and motor developmental score (WMD = 9.54; 95% CI 6.6-12.4 heterogeneity I2 = 0%; P = 0.52). There was no effect on head circumference and total developmental score. Evidence is "moderate" certainty for weight and length and "very low" certainty for neurodevelopment.

CONCLUSION

Zinc supplementation may enhance weight gain and linear growth in preterm infants. There is a lack of data about relationship between zinc supplementation and neurodevelopment.

Neonatal Group B Streptococcal Meningitis: Predictors for Poor Neurologic Outcome at 18 Months

AIM

To find early predictors for poor neurodevelopmental outcome after neonatal group B streptococcal meningitis.

METHODS

We retrospectively analyzed clinical characteristics of 23 patients with neonatal group B streptococcal meningitis and their neurodevelopmental outcome at 18 months. Available group B Streptococcus strains were serotyped and their genomes characterized.

RESULTS

We found several differences between patients with early- (n = 5) and late-onset (n = 18) disease. Nine children had neurologic abnormalities at 18 months and 4 had epilepsy, all of them after late-onset disease. Most important risk factors for poor outcome were impaired consciousness at admission, hemodynamic instability, seizures, or abnormal electroencephalogram during the acute illness and abnormal neurologic and ophthalmologic examination at the end of treatment, whereas abnormalities in laboratory and imaging studies were not predictive. Hypervirulent serotype III, multilocus sequence type 17 group B Streptococcus was the predominant pathogen.

CONCLUSIONS

Neurodevelopmental impairment after neonatal group B streptococcal meningitis is likelier in those with clinical and neurophysiological features indicating worse disease severity.

Prognostic Value of Various Diagnostic Methods for Long-Term Outcome of Newborns After Hypoxic-Ischemic Encephalopathy Treated With Hypothermia

INTRODUCTION

Prediction of outcome in newborns with hypoxic-ischemic encephalopathy (HIE) has been modulated by hypothermia treatment (HT). We assessed the predictive value of diagnostic methods commonly used in neonates with HIE for short-term neurodevelopmental outcome and long-term neurological outcome.

MATERIALS AND METHODS

This longitudinal cohort study followed up 50 term newborns who underwent HT after HIE between July 2006 and August 2015, until preschool age. We estimated sensitivity and specificity for short-term neurodevelopmental outcome at 18 months and long-term neurological outcome at five years based on Amiel-Tison Neurological Assessment (ATNA), electroencephalography (EEG), and magnetic resonance imaging (MRI) performed in the neonatal period.

RESULTS

The accuracy of all neonatal methods tested was higher for long-term neurological outcome compared to the predictive accuracy for short-term neurodevelopmental outcome at 18-24 months. Sensitivity and specificity in predicting unfavorable long-term neurological outcome were: MRI (sensitivity 1.0 [95%CI 0.96-1.0]; specificity 0.91 [95%CI 0.86-1.0]), EEG (sensitivity 0.94 [95%CI 0.71-1.0]; specificity 1.0 [95% CI 0.89-1.0]), and ATNA (sensitivity 0.94 [95%CI 0.71-1.0]; specificity 0.91 [95%CI 0.76-0.98]).

CONCLUSION

MRI is a powerful predictor of long-term neurological outcome when performed in the first week after HIE in HT treated infants, as are EEG and ATNA performed in the second or third week postnatally.

Genetic-cellular epilepsy: Clues to diagnosing newborns with neonatal seizures

OBJECTIVE

The aim of this study was to analyse clinical characteristics of newborns with genetic-cellular epilepsy (GCE) to compare them to those of newborns with seizures with other aetiologies and elucidate clues to the diagnosis of GCE.

METHODS

This retrospective single-centre study analysed data from an 8-year cohort of newborns with seizures from 2010-2017. Clinical, neurophysiological, laboratory, and imaging data and outcomes of children with GCE were compared to those of newborns with seizures with other aetiologies.

RESULTS

A total of 112 newborns (N = 68; 61% boys) were included. Hypoxic-ischaemic encephalopathy (N = 42; 29%) was the most common seizure aetiology; GCE (with pathogenic variants KCNQ2, KCNQ3, SCN2A, TBC1D24, CHD2, and STXBP) was diagnosed in 9 (6%). The group of newborns with GCE significantly differed from the group with seizures with other aetiologies in terms of family history of epilepsy (p = 0.000), neonatal epileptic status (NES) (p = 0.007), normal imaging studies (p = 0.000), and outcomes (p = 0.034), but did not differ regarding the type and age of seizure onset, number of antiepileptic drugs administered, and EEG results. Positive family history of epilepsy (p = 0.027), presence of NES (p = 0.041), and normal imaging studies (p = 0.002) were most indicative of the diagnosis of GCE. Probability of GCE with this combination was 0.92.

CONCLUSION

In a heterogenous group of newborns with seizures, a positive family history of epilepsy, presence of NES, and normal imaging studies were most indicative of the diagnosis of GCE.

Neurodevelopmental outcome of preterm very low birth weight infants admitted to an Italian tertiary center over an 11-year period

Preterm very low birth weight infants (VLBWi) are known to be at greater risk of adverse neurodevelopmental outcome. Identifying early factors associated with outcome is essential in order to refer patients for early intervention. Few studies have investigated neurodevelopmental outcome in Italian VLBWi. The aim of our longitudinal study is to describe neurodevelopmental outcome at 24 months of corrected age in an eleven-year cohort of 502 Italian preterm VLBWi and to identify associations with outcome. At 24 months, Griffiths’ Mental Developmental Scales were administered. Neurodevelopmental outcome was classified as: normal, minor sequelae (minor neurological signs, General Quotient between 76 and 87), major sequelae (cerebral palsy; General Quotient ≤ 75; severe sensory impairment). 75.3% showed a normal outcome, 13.9% minor sequelae and 10.8% major sequelae (3.8% cerebral palsy). Male gender, bronchopulmonary dysplasia, abnormal neonatal neurological assessment and severe brain ultrasound abnormalities were independently associated with poor outcome on multivariate ordered logistic regression. Rates of major sequelae are in line with international studies, as is the prevalence of developmental delay over cerebral palsy. Analysis of perinatal complications and the combination of close cUS monitoring and neurological assessment are still essential for early identification of infants with adverse outcome.

Structural Changes in the Cortico-Ponto-Cerebellar Axis at Birth are Associated with Abnormal Neurological Outcomes in Childhood

White matter lesions in hypoxic-ischemic encephalopathy (HIE) are considered to be the important substrate of frequent neurological consequences in preterm infants. The aim of the study was to analyze volumes and tractographic parameters of the cortico-ponto-cerebellar axis to assess alterations in the periventricular fiber system and crossroads, corticopontine and corticospinal pathways and prospective transsynaptic changes of the cerebellum.Term infants (control), premature infants without (normotypic) and with perinatal HIE (HIE) underwent brain magnetic resonance imaging at term-equivalent age (TEA) and at 2 years. Cerebrum, cerebellum, brainstem divisions and ventrodorsal compartments volumetric analysis were performed, as well as fractional anisotropy (FA) and apparent diffusion coefficient (ADC) of corticopontine, corticospinal pathways and middle cerebellar peduncles. Amiel-Tison scale at TEA and the Hempel test at 2 years were assessed.Cerebellum, brainstem and its compartments volumes were decreased in normotypic and HIE groups at TEA, while at 2 years volumes were significantly reduced in the HIE group, accompanied by decreased volume and FA and increased ADC of corticopontine and corticospinal pathways. Negative association of the brainstem, cerebellum, mesencephalon, pons, corticopontine volumes and corticospinal pathway FA at TEA with the neurological score at 2 years. Cerebellum and pons volumes presented as potential prognostic indicators of neurological outcomes.Our findings agree that these pathways, as a part of the periventricular fiber system and crossroads, exhibit lesion-induced reaction and vulnerability in HIE. Structural differences between normotypic and HIE group at the 2 years suggest a different developmental structural plasticity.

Effect of Therapeutic Hypothermia on the Outcome in Term Neonates with Hypoxic Ischemic Encephalopathy-A Randomized Controlled Trial

OBJECTIVE

To assess the effect of therapeutic hypothermia on the outcome in term neonates with hypoxic ischemic encephalopathy (HIE).

METHODS

A randomized controlled trial was conducted in a tertiary care teaching hospital in south India. Term infants with moderate to severe HIE were randomized to be treated with normothermia or hypothermia. Mortality, neurological abnormality or normal outcome was recorded at hospital discharge or 28 days of age, whichever was earlier, and at 18 months of age.

RESULTS

The baseline maternal and neonatal characteristics in the two groups were similar. The 78 infants in the hypothermia group had more normal survivors at discharge (38%) than the 84 infants in the normothermia group (30%), ratio 1.29 (95% confidence interval 0.84-1.99), and at 18 months of age (65% vs. 42%), ratio 1.54 (1.13-2.10). When these results were combined with those of a previous randomized trial in the same neonatal unit, there were significantly more normal survivors with hypothermia compared to normothermia at discharge, ratio 1.49 (1.18-1.88) and at 6-18 months of age, ratio 1.37 (1.17-1.60).

CONCLUSION

In term infants with HIE, therapeutic hypothermia reduced mortality and neurological abnormalities, and resulted in more normal survivors.

LAY SUMMARY

Babies who do not breathe immediately after they are born are likely to die or have brain damage. Previous studies have suggested that cooling these babies after birth might reduce the number who die or have brain damage. In this resource-limited setting, babies who were cooled were less likely to die or survive with brain damage.

Oral melatonin as a new tool for neuroprotection in preterm newborns: study protocol for a randomized controlled trial

Background

Prevention of neurodevelopmental impairment due to preterm birth is a major health challenge. Despite advanced obstetric and neonatal care, to date there are few neuroprotective molecules available. Melatonin has been shown to have anti-oxidant/anti-inflammatory effects and to reduce brain damage, mainly after hypoxic ischemic encephalopathy. The planned study will be the first aiming to evaluate the capacity of melatonin to mitigate brain impairment due to premature birth.

Method

In our planned prospective, multicenter, double-blind, randomized vs placebo study, we will recruit, within 96 h of birth, 60 preterm newborns with a gestational age ≤ 29 weeks + 6 days; these infants will be randomly allocated to oral melatonin, 3 mg/kg/day, or placebo for 15 days. After the administration period, we will measure plasma levels of malondialdehyde, a lipid peroxidation product considered an early biological marker of melatonin treatment efficacy (primary outcome). At term-equivalent age, we will evaluate neurological status (through cerebral ultrasound, cerebral magnetic resonance imaging, vision and hearing evaluations, clinical neurological assessment, and screening for retinopathy of prematurity) as well as the incidence of bronchodysplasia and sepsis. We will also monitor neurodevelopmental outcome during the first 24 months of corrected age (using the modified Fagan Test of Infant Intelligence at 4–6 months and standardized neurological and developmental assessments at 24 months).

Discussion

Preterm birth survivors often present long-term neurodevelopmental sequelae, such as motor, learning, social-behavioral, and communication problems. We aim to assess the role of melatonin as a neuroprotectant during the first weeks of extrauterine life, when preterm infants are unable to produce it spontaneously. This approach is based on the supposition that its anti-oxidant mechanism could be useful in preventing neurodevelopmental impairment. Considering the short- and long-term morbidities related to preterm birth, and the financial and social costs of the care of preterm infants, both at birth and over time, we suggest that melatonin administration could lead to considerable saving of resources. This would be the first study addressing the role of melatonin in very low birth weight preterm newborns, and it could provide a basis for further studies on melatonin as a neuroprotection strategy in this vulnerable population.

Trial registration

ClinicalTrials.gov NCT04235673. Prospectively registered on 22 January 2020.

Additional benefits of three-dimensional ultrasound for prenatal assessment of twins

Three-dimensional ultrasound (3DUS) may provide additional information for prenatal assessment of twins. It may improve the diagnostic confidence of dating, nuchal translucency (NT) and chorionicity assignment in twin pregnancies. The "virtual 3DUS placentoscopy" can guide selective fetoscopic laser photocoagulation (SFLP) to treat twin-twin transfusion syndrome (TTTS). Volumetric assessment of the dysmorphic acardiac twin with the Virtual Organ Computer-aided Analysis (VOCAL) software is more accurate than the conventional ultrasound measurement. Twin anemia polycythemia (TAP) sequence and selective intrauterine growth restriction (sIUGR) may be clinically monitored with 3DUS placental volume (PV) and power Doppler vascular indices. Congenital anomalies are more common in twins. Evaluation of fetal anomalies with 3DUS could assist perinatal management. The 3DUS power Doppler can provide a better understanding of true and false umbilical cord knots, which are commonly found in monoamniotic (MA) twins. Single demise in monochorionic (MC) twin pregnancies can cause severe neurologic morbidity in the surviving co-twin. Prenatal prediction of brain injury in the surviving co-twin with unremarkable neurosonographic examination is difficult. The 3DUS power Doppler may aid in prenatal detection of subtle abnormal cerebral perfusion. Prenatal assessment of conjoined twins with 3DUS is important if emergency postnatal surgical separation is anticipated. There is no significant additional advantage in using real-time 3DUS to guide prenatal interventions. Assessment of the cervix and pelvic floor during twin pregnancies is enhanced with 3DUS. Due to lack of high-quality studies, routine prenatal 3DUS in twin pregnancies needs to be balanced with risks of excessive ultrasound exposure.

Assessment of neonatal EEG background and neurodevelopment in full-term small for their gestational age infants

BACKGROUND

Delayed brain function development in small-gestational-age (SGA) infants has been reported. We aimed to quantify rates of immature neonatal EEG patterns and their association with neurodevelopment in SGA full-term neonates.

METHODS

Using a cohort design, 50 SGA (birthweight <10th percentile) and 44 appropriate-gestational-age (AGA) term neonates underwent continuous video-EEG recordings lasting >3 h. Seventy-three of them were assessed at 2-years-old using Bayley-III-Scales. For EEG analysis, several segments of discontinuous/alternating EEG tracings were selected.

MAIN OUTCOMES MEASURED

(1) Visual analysis (patterns of EEG maturity); (2) Power spectrum in δ, θ, α and β frequency bands; and (3) scores in motor, cognitive and language development.

RESULTS

(1) SGA infants, compared to AGA, showed: (a) higher percentages of discontinuous EEG, both asynchrony and interhemispheric asymmetry, and bursts with delta-brushes, longer interburst-interval duration and more transients/hour; (b) lower relative power spectrum in δ and higher in α; and (c) lower scores on motor, language and cognitive neurodevelopment. (2) Asymmetry >5%, interburst-interval >5 s, discontinuity >11%, and bursts with delta-brushes >11% were associated with lower scores on Bayley-III.

CONCLUSIONS

In this prospective study, SGA full-term neonates showed high rates of immature EEG patterns. Low-birthweight and immaturity EEG were both correlated with low development scores.

Goniometric Assessment of Muscle Tone of Preterm Infants and Impact of Gestational Age on Its Maturation in Indian Setting

Context:

The normative data on muscle tone of preterm infants by goniometric assessment in Indian setting are scarce.

Aim:

The aim of this study it to provide a normative objective data of muscle tone of preterm infants by gestation using goniometer.

Settings and Design:

This was a prospective, observational study including preterm infants admitted in a tertiary care hospital from North India.

Subjects and Methods:

The objective dimension of muscle tone assessment of 204 healthy preterm infants was done; 61 infants completed follow-up till 40 weeks’ postconceptional age (PCA) and were compared to term infants.

Statistical Analysis Used:

SPSS (version 16.0) was used. The intergroup comparison was done through ANOVA, and the localization of differences between the groups was determined through multiple comparisons by post hoc test.

Results:

Mean gestational age was 34.3 ± 1.7 weeks. Angles were as follows: adductor = 100.1 ± 8.7, popliteal = 118.9 ± 8.6, dorsiflexion = 39.0 ± 9.0, heel to ear = 121.90 ± 7.90, wrist flexion = 46.0 ± 10.2, and arm recoil = 122.2° ± 16.6°. The evolution of muscle tone as indicated by heel-to-ear angle shows progressive maturation from 32 weeks’ gestation while adductor angle, popliteal angle, and arm recoil mature predominantly after 36 weeks’ gestation. Comparison of preterm infants to term at 40 weeks’ PCA demonstrated significantly less tone in all except posture and heel to ear.

Conclusions:

Goniometric assessment provides a objective normative data of muscle tone for preterm infants. Maturation of heel to ear and posture evolves from 32 weeks onwards and are the earliest neurologic marker to mature in preterm infants independent of the gestational age at birth.

Recommendations for the design of therapeutic trials for neonatal seizures

Although seizures have a higher incidence in neonates than any other age group and are associated with significant mortality and neurodevelopmental disability, treatment is largely guided by physician preference and tradition, due to a lack of data from well-designed clinical trials. There is increasing interest in conducting trials of novel drugs to treat neonatal seizures, but the unique characteristics of this disorder and patient population require special consideration with regard to trial design. The Critical Path Institute formed a global working group of experts and key stakeholders from academia, the pharmaceutical industry, regulatory agencies, neonatal nurse associations, and patient advocacy groups to develop consensus recommendations for design of clinical trials to treat neonatal seizures. The broad expertise and perspectives of this group were invaluable in developing recommendations addressing: (1) use of neonate-specific adaptive trial designs, (2) inclusion/exclusion criteria, (3) stratification and randomization, (4) statistical analysis, (5) safety monitoring, and (6) definitions of important outcomes. The guidelines are based on available literature and expert consensus, pharmacokinetic analyses, ethical considerations, and parental concerns. These recommendations will ultimately facilitate development of a Master Protocol and design of efficient and successful drug trials to improve the treatment and outcome for this highly vulnerable population.

Turkish Neonatal Society Guideline on neonatal encephalopathy

Neonatal encephalopathy is a major cause of neonatal mortality and morbidity. Therapeutic hypothermia is standard treatment for newborns at 35 weeks of gestation or more with intrapartum hypoxia-related neonatal encephalopathy. Term and late preterm infants with moderate-to-severe encephalopathy show improved survival and neurodevelopmental outcomes at 18 months of age after therapeutic hypothermia. Therapeutic hypothermia can increase survival without increasing major disability. Neonates with severe neonatal encephalopathy remain at risk of death or severe neurodevelopmental impairment. This guideline was prepared by the Turkish Neonatal Society to standardize the management of neonatal encephalopathy throughout the country.

Prediction of postnatal developmental disabilities using the antenatal fetal neurodevelopmental test: KANET assessment

Objective To assess the usefulness of the antenatal fetal neurodevelopmental test for the prediction of postnatal developmental disabilities. Methods Fetal behavior was assessed with Kurjak's antenatal neurodevelopmental test (KANET) using four-dimensional ultrasound between 28 and 38 weeks of gestation. A score range of 0-5 was characterized as abnormal, from 6 to 9 was considered borderline, and 10-16 was normal. After birth, follow-up was conducted for at least 2 years in all fetuses. Results There were 337 normal (95.47%) and 16 borderline (4.53%) cases among the 353 cases studied, whereas there was no abnormal case. Five cases with postnatal developmental disabilities (one case of Werdig-Hoffmann disease diagnosed just after delivery, one case of autism spectrum disorder diagnosed at 24 months, one case of Ullrich congenital muscular dystrophy diagnosed at 9 months and two cases of developmental disorders diagnosed at age 3 and 18 months) were noted among the 337 normal cases (1.48%), whereas three cases with developmental disabilities (one case of motor development delay diagnosed at 6 months, one case of Duchenne muscular dystrophy diagnosed at 18 months and one case of autism spectrum disorder diagnosed at age 30 months) were found among the 16 borderline cases (18.75%). There was a significant difference in the prevalence of postnatal developmental disabilities between the normal and borderline KANET groups (P<0.001). Conclusion Our results suggest that the KANET assessment may be a useful diagnostic modality for the prediction of postnatal developmental disabilities.

Elevated brain oxygen extraction fraction in preterm newborns with anemia measured using noninvasive MRI

OBJECTIVE

To test the hypothesis that cerebral oxygen extraction fraction (OEF) is elevated and inversely related to hematocrit level in anemic former very-low-birth-weight infants near term.

STUDY DESIGN

Prospective study of non-sedated preterm infants (post-menstrual age = 36 ± 2 weeks) over a range of hematocrits (0.23-0.49). Anatomical (T₁-W, T₂-W, and diffusion-weighted), cerebral blood flow (CBF), and OEF 3-T MRI were utilized. Statistical analysis included Spearman's rank-order correlation testing between study variables and intraclass correlation coefficients (ICC) calculated between consecutively acquired OEF scans.

RESULTS

Consecutive OEF measurements showed moderate-to-good agreement (ICC = 0.71; 95% CI = 0.40-0.87). OEF increased with worsening anemia (ρ = -0.58; p = 0.005), and OEF and basal ganglia CBF were positively correlated (ρ = 0.49; p = 0.023).

CONCLUSION

Noninvasive OEF MRI has moderate-to-good repeatability in non-sedated former preterm infants nearing term-equivalent age. Strong correlation of elevated OEF with anemia suggests hemodynamic compensation for anemia and could establish OEF as a useful biomarker of transfusion threshold for preterm infants.

Anterior Fontanelle Size in Healthy Indian Late Preterm and Full Term Newborns

OBJECTIVE

To measure the size of the anterior fontanelle (AF) in healthy late-preterm and term newborns and correlate it with birth weight, gestational age, gender, occipito-frontal circumference, small for gestational age status and birth weight z-score.

METHODS

This was an observational study carried out from October 2013 through April 2015 at a tertiary care hospital. Newborns ≥ 34 wk gestation were enrolled. Fontanelle edge was palpated with index finger and size calculated by adding anterior-posterior and transverse diameters and dividing by two.

RESULTS

A total of 1010 neonates were enrolled. The mean AF size was 2.23 ± 0.52 cm (mean ± SD). There was a significant decrease in the size of the AF with advancing gestational maturity on one-way ANOVA (F = 31.30) (P < 0.001) and also by increasing birth weight (F = 20.34) (P < 0.001). There was no significant difference in the mean AF size between males; 2.21 ± 0.54 cm and females; 2.25 ± 0.55 cm (mean ± SD) (P = 0.575). There was a strong correlation between AF size with increasing birth weight; correlation (r) = 0.985. In small for gestational age neonates the AF was larger, 2.27 ± 0.55 (mean ± SD) and a strong correlation between birth weight z-score and AF size was noted (r = 1.012).

CONCLUSIONS

The mean AF size in late-preterm and term Indian newborns in a mixed community hospital was 2.23 ± 0.52. A strong correlation was found between AF size with increasing birth weight and with birth weight z-score in small for gestational age babies.

Clinical study of fetal neurobehavior by the KANET test

Fetal neurology is evolving as an area of great interest in prenatal diagnosis and fetal medicine. The identification and diagnosis of brain damage prenatally has been a great challenge in obstetrics for many years. Investigations of fetal behavior in comparison with morphological studies led to the conclusion that fetal behavioral patterns directly reflect developmental and maturational processes of the fetal central nervous system (CNS). Four-dimensional (4D) ultrasound has greatly improved the assessment of the quality of the fetal spontaneous movements, and enabled a better evaluation of fetal behavior. The assessment of normal neurobehavioral development by 4D ultrasound provided the opportunity to investigate functional characteristics of the fetus that could predict neurological developmental dysfunction. Some studies have already been carried out to evaluate this new methodology in the observation of fetal behavior during different stages of gestation, in an attempt to better understand the relationships between the maturation of the CNS of the fetus and its implications on its behavior pattern. We present a review of literature on fetal behavior by 4D ultrasound.

Maturational Changes of Delta Waves in Monozygotic and Dizygotic Infant Twins

AIMS

To compare developmental changes of delta 1 (0.5-2.0 Hz) and delta 2 (2.25-3.75 Hz) power spectra between healthy monozygotic (MZ) and dizygotic (DZ) twin pairs and among MZ and DZ twin groups during active/REM (AS/REM) and quiet/NREM (QS/NREM) sleep stages at 38th, 46th, and 52nd weeks of postmenstrual age (PMA).

MATERIALS AND METHODS

Electroencephalography (EEG) recordings were analyzed using fast Fourier transforms. Differences in the developmental changes of delta power within twin pairs and between twin groups were estimated by calculating mean absolute differences of relative spectral values in delta 1 (0.5-2 Hz) and delta 2 (2.25-3.75 Hz) frequencies.

RESULTS

A review of electrodes showed that relative delta 1 power decreased, whereas delta 2 power increased from 38th toward 52nd week of PMA regardless of zygosity, sleep stages, and electrode position. Twin groups did not significantly differ (P > .05) in within-pair MZ and DZ similarity for delta 1 and delta 2 power spectra; similarity between MZ twin partners for delta 1 and delta 2 power spectra was as high as that of DZ twin partners on each electrode position, sleep stage, and period of measurement.

CONCLUSIONS

Developmental changes of delta 1 and delta 2 power spectra occurred equally in MZ and DZ twin groups during AS and QS sleep stages at 38th, 46th, and 52th PMA. The rhythm of EEG maturation evidenced by the maturation of delta 1 and delta 2 power spectra was not dependent on zygosity.

Predictors of Poor Outcome in Neonates with Pyogenic Meningitis in a Level-Three Neonatal Intensive Care Unit of Developing Country

BACKGROUND

The mortality of neonatal pyogenic meningitis is reduced to 10-15%, but morbidity is unchanged.

METHODS

Primary objective is to determine the outcome, i.e. death or abnormal neurological examination (NE) at discharge and abnormal developmental quotient (DQ) at 3 months. Secondary objective is to find predictors of poor outcome.

RESULTS

In all, 89 neonates enrolled, 10 expired and 24 neonates had abnormal NE at discharge. A total of 59 neonates came for follow up, 13 had DQ < 70. Prolonged shock (odds ratio, OR: 8.28; p = 0.001), coma (OR: 4.3; p = 0.001), seizures (OR: 14; p = 0.012), mechanical ventilation (OR: 18.55; p = 0.00), orogastric feeding (OR: 2.78; p = 0.042) and electroencephalography (EEG; OR: 9.6; p = 0.00) predicted poor short-term outcome. Abnormal NE at discharge (OR: 15.6; p = 0.001), EEG (OR = 10.60; p = 0.00) and brainstem-evoked reflex audiometry (OR = 37.20, p = 0.00) predicted a low DQ at 3 months. Mortality and morbidity of neonates with Pyogenic Meningitis (PM) were similar to that in developed countries. Outcome depended on severity of the disease and NE at discharge.

LyTONEPAL: long term outcome of neonatal hypoxic encephalopathy in the era of neuroprotective treatment with hypothermia: a French population-based cohort

Background

Hypoxic-ischemic encephalopathy (HIE) is a rare neonatal condition affecting about 1‰ births. Despite a significant improvement in the management of this condition in the last ten years, HIE remains associated with high rates of death and severe neurological disability. From September 2015 to March 2017, a French national cohort of HIE cases was conducted to estimate the extent of long-term moderate and severe neurodevelopmental disability at 3 years and its determinants.

Methods

This prospective population-based cohort includes all moderate or severe cases of HIE, occurring in newborns delivered between 34 and 42 completed weeks of gestation and admitted to a neonatal intensive care unit. Detailed data on the pregnancy, delivery, and newborn until hospital discharge was collected from the medical records in maternity and neonatology units. All clinical examinations including biomarkers, EEG, and imaging were recorded. To ensure the completeness of HIE registration, a registry of non-included eligible neonates was organized, and the exhaustiveness of the cohort is currently checked using the national hospital discharge database. Follow-up is organized by the regional perinatal network, and 3 medical visits are planned at 18, 24 and 36 months. One additional project focused on early predictors, in particular early biomarkers, involves a quarter of the cohort.

Discussion

This cohort study aims to improve and update our knowledge about the incidence, the prognosis and the etiology of HIE, and to assess medical care. Its final objective is to improve the definition of this condition and develop prevention and management strategies for high-risk infants.

Trial registration

NCT02676063. Date of registration (Retrospectively Registered): February 8, 2016.

Neuroimaging perspectives on fetal motor behavior

We are entering a new era of understanding human development with the ability to perform studies at the earliest time points possible. There is a substantial body of evidence to support the concept that early motor behaviour originates from supraspinal motor centres, reflects neurological integrity, and that altered patterns of behaviour precede clinical manifestation of disease. Cine Magnetic Resonance Imaging (cineMRI) has established its value as a novel method to visualise motor behaviour in the human fetus, building on the wealth of knowledge gleaned from ultrasound based studies. This paper presents a state of the art review incorporating findings from human and preclinical models, the insights from which, we propose, can proceed a reconceptualisation of fetal motor behaviour using advanced imaging techniques. Foremost is the need to better understand the role of the intrauterine environment, and its inherent unique set of stimuli that activate sensorimotor pathways and shape early brain development. Finally, an improved model of early motor development, combined with multimodal imaging, will provide a novel source of in utero biomarkers predictive of neurodevelopmental disorders.

Placental transfusion in preterm neonates of 30-33 weeks' gestation: a randomized controlled trial

OBJECTIVES

To compare effect of placental transfusion by delayed cord clamping (DCC) or cord milking (CM) with early cord clamping (ECC) on a composite of mortality or abnormal neurological status at 40 weeks' post-menstrual age (PMA) and 24-30 months' chronological age in neonates of 30-33 weeks' gestation.

STUDY DESIGN

Randomized, controlled trial.

OUTCOMES

A composite of mortality or abnormal neurological status at 40 weeks PMA and survival free of neurodevelopmental abnormalities at 24-30 months' chronological age.

RESULTS

A total of 461 neonates were randomized to placental transfusion (n = 233) or to ECC (n = 228). Among those assigned to placental transfusion group, 173 underwent DCC while in the remaining 60, CM was done. Incidence of mortality or abnormal neurological status at 40 weeks PMA (43 (18%) vs 35 (15%), RR (95% CI) 1.2 (0.8, 1.8), p = 0.4) and survival free of neurodevelopmental impairment at 24-30 months of chronological age (99 (47%) vs. 100 (50%); RR (95% CI): 0.9 (0.8, 1.2); P = 0.9) was similar between the study groups. The placental transfusion group showed a trend towards lower incidence of necrotizing enterocolitis.

CONCLUSION

In 30-33 weeks' gestation preterm neonates, placental transfusion as compared to early cord clamping resulted in similar mortality or abnormal neurological status at 40 weeks PMA and at 24-30 months of chronological age.

One-Year Outcome for Congenital Diaphragmatic Hernia: Results From the French National Register

OBJECTIVE

To evaluate the status of congenital diaphragmatic hernia (CDH) management in France and to assess predictors of adverse outcomes.

STUDY DESIGN

We reviewed the first-year outcome of all cases of CDH reported to the French National Register in 2011.

RESULTS

A total of 158 cases were included. Of these, 83% (131) were prenatally diagnosed, with a mortality rate of 39% (44 of 112) for live born infants with a known outcome at hospital discharge. Mortality increased to 47% (60 of 128) including those with termination of pregnancy and fetal loss. This contrasts with the 7% (2 of 27) mortality rate of the patients diagnosed postnatally (P = .002). Mortality worsened with 1 prenatal marker of CDH severity (OR 3.38 [1.30-8.83] P = .013) and worsened further with 2 markers (OR 20.64 [5.29-80.62] P < .001). Classic postnatal risk factors of mortality such as side of hernia (nonleft P = .001), prematurity (P < .001), low birth weight (P = .002), and size of the defect (P < .001) were confirmed. Of the 141 live births (114 prenatal and 27 postnatal diagnosis) with known outcomes, 93 (67%) survived to hospital discharge, 68 (60%) with a prenatal diagnosis and 25 (93%) with a postnatal diagnosis. The median time to hospital discharge was 34 days (IQR, 19.25-62). Of these survivors, 71 (76%) were followed up for 1 year.

CONCLUSIONS

Despite advances in management of CDH, mortality was high and associated with prenatal risk factors. Postnatally, severe persistent pulmonary hypertension was difficult to predict and presented persistent challenges in management.

In Preterm Infants, Length Growth below Expected Growth during Hospital Stay Predicts Poor Neurodevelopment at 2 Years

BACKGROUND

In preterm infants, neonatal weight growth is associated with neurodevelopmental outcome but is a poor indicator of growth quality.

OBJECTIVE

The aim of this work was to measure the relationship between neonatal length growth and the 2-year neurological outcome in preterm infants.

METHODS

A total of 2,403 infants enrolled in the LIFT cohort with gestational age less than 34 weeks were studied. Neonatal observed length growth (OLG) was calculated as the change in length Z-score between birth and discharge. Expected length growth (ELG) was estimated based on gestational age, birth weight Z-score, birth length Z-score, gender, and observed neonatal weight growth. The difference between OLG and ELG (∆OLG-ELG) was calculated as OLG - ELG, and infants were ranked into 3 classes depending on their ∆OLG-ELG (≤-0.5, -0.49 to 0.49, ≥0.50 Z-score). We explored the relationship between ∆OLG-ELG and 2-year neurodevelopmental outcome (n = 2,036), and, in a subgroup (n = 85), between ∆OLG-ELG and body composition at discharge.

RESULTS

ELG was strongly predicted from the above-mentioned parameters (R2 = 0.73, p = 0.001). OLG correlated closely with gestational age (p = 0.001) but ∆OLG-ELG did not (p = 1.0). OLG was not associated with a 2-year nonoptimal outcome after adjustment for gestational age, but ∆OLG-ELG ≤-0.5 was; the crude and adjusted odds ratios were 1.63 and 1.56, respectively. ∆OLG-ELG correlated negatively with fat mass (R2 = 0.29, p = 0.006) before and after adjustment for gestational age.

CONCLUSION

∆OLG-ELG is a marker of neonatal growth that does not depend on gestational age, and may reflect quality of growth. A ∆OLG-ELG ≤-0.5 Z-score is associated with a higher risk for 2-year nonoptimal neurodevelopmental outcome.

Impact of preterm birth on parental separation: a French population-based longitudinal study

OBJECTIVE

The objective of this study was to investigate both the effects of low gestational age and infant's neurodevelopmental outcome at 2 years of age on the risk of parental separation within 7 years of giving birth.

DESIGN

Prospective.

SETTING

24 maternity clinics in the Pays-de-la-Loire region.

PARTICIPANTS

This study included 5732 infants delivered at <35 weeks of gestation born between 2005 and 2013 who were enrolled in the population-based Loire Infant Follow-up Team cohort and who had a neurodevelopmental evaluation at 2 years. This neurodevelopmental evaluation was based on a physical examination, a psychomotor evaluation and a parent-completed questionnaire.

OUTCOME MEASURE

Risk of parental separation (parents living together or parents living separately).

RESULTS

Ten percent (572/5732) of the parents reported having undergone separation during the follow-up period. A mediation analysis showed that low gestational age had no direct effect on the risk of parental separation. Moreover, a non-optimal neurodevelopment at 2 years was associated with an increased risk of parental separation corresponding to a HR=1.49(1.23 to 1.80). Finally, the increased risk of parental separation was aggravated by low socioeconomic conditions.

CONCLUSIONS

The effect of low gestational age on the risk of parental separation was mediated by the infant's neurodevelopment.

Implementation of Early Diagnosis and Intervention Guidelines for Cerebral Palsy in a High-Risk Infant Follow-Up Clinic

BACKGROUND

Cerebral palsy is the most common physical disability in childhood, and is mostly diagnosed after age 2 years. Delays in diagnosis can have negative long-term consequences for children and parents. New guidelines for early cerebral palsy diagnosis and intervention were recently published, after systematic review of the evidence by international multidisciplinary experts aiming to decrease age at diagnosis. The current study tested the feasibility of implementing these guidelines in an American clinical setting.

METHODS

We designed a stepwise implementation process in a neonatal intensive care follow-up clinic. Efficacy was tested by comparing 10-month pre- and post-implementation periods. Clinic visit types, cerebral palsy diagnosis, provider competencies and perspectives, and balancing measures were analyzed.

RESULTS

Changes to infrastructure, assessments, scheduling algorithms, documentation and supports in diagnosis or counseling were successfully implemented. Number of three- to four-month screening visits increased (255 to 499, P < 0.001); mean age at diagnosis decreased (18 to 13 months, P < 0.001). Clinic team awareness of early diagnosis and interventions increased (P < 0.001). There was no decrease in family satisfaction with overall clinic function. Opportunities for improvements included documentation for transitioning patients, generalizabilty across hospital clinics, systematic identification of high-risk status during hospitalization, and need for cerebral palsy care guidelines for infants under age 2 years.

CONCLUSIONS

We demonstrated for the first time in a US clinical setting the feasibility of implementation of international early diagnosis and treatment guidelines for cerebral palsy. This process is adaptable to other settings and underscores the necessity of future research on cerebral palsy treatments in infancy.

An Italian Prospective Experience on the Association Between Congenital Cytomegalovirus Infection and Autistic Spectrum Disorder

The aim of this retrospective study, with prospective data collection, was to correlate congenital cytomegalovirus (CMV) infection with autism spectrum disorder (ASD) and to define its prevalence. Seventy proven congenitally-infected infants, born between 2007 and 2012, were referred to our centre for CMV diagnosis and follow-up, which consisted of a consolidated protocol allowing an early evaluation of autism. We considered four children 2-year old, two of whom, at the age of 3, were diagnosed with ASD demonstrating a 2-3 fold higher prevalence (2.86%), than that in general Italian population (0.66-1.36%).Our protocol enabled us to make the earliest diagnosis and highlight the role of the virus among other causes of autism, which may be a long term sequela of congenital CMV.

Neurodevelopmental Outcome of Asymptomatic Hypoglycemia Compared With Symptomatic Hypoglycemia and Euglycemia in High-Risk Neonates

AIMS

We assessed the neurodevelopmental outcome at one year of age of children with asymptomatic neonatal hypoglycemia and compared their outcome with that of symptomatic hypoglycemic and euglycemic neonates.

METHOD

Seventy two hypoglycemic (plasma glucose less than 50 mg/dL) neonates, both symptomatic (n = 27) and asymptomatic (n = 45), and 70 weight- and gestation-matched euglycemic neonates of gestational age greater than 32 weeks were enrolled during the first week of life then assessed for neurodevelopmental outcome at corrected age six and 12 months (n = 67 and 62 in hypoglycemia group and 63 and 54 in euglycemia group, with the rest lost to follow-up, and death = 1).

RESULTS

At one year, 8% (five of 62, four in symptomatic and one in asymptomatic group) of hypoglycemic neonates developed cerebral palsy. Mean motor and mental development quotients were significantly lower at corrected ages six and 12 months in any hypoglycemia (P < 0.001) and if blood glucose was less than 40 mg/dL (P < 0.001) when compared with euglycemia. Symptomatic infants had lower motor development quotient (P = 0.004 and 0.003) and mental development quotient (P = 0.001 and 0.001) at corrected ages six and 12 months than asymptomatic infants, and asymptomatic infants had lower motor development quotient (P ≤ 0.001 and 0.004) and mental development quotient (P = 0.001 and 0.004) than the euglycemic group at corrected ages six and 12 months, respectively. Blood glucose of less than 40 mg/dL had high sensitivity (83% for motor development quotient and 81% for mental development quotient) for development quotient scores of less than 85.

CONCLUSION

Hypoglycemia, both symptomatic and asymptomatic, leads to adverse neurodevelopmental outcome when compared with euglycemia, although it was worse in the symptomatic group and at blood glucose less than 40 mg/dL.

Inflammatory and vascular placental lesions are associated with neonatal amplitude integrated EEG recording in early premature neonates

INTRODUCTION

Placental histologic examination can assist in revealing the mechanism leading to preterm birth. Accumulating evidence suggests an association between intrauterine pathological processes, morbidity and mortality of premature infants, and their long term outcome. Neonatal brain activity is increasingly monitored in neonatal intensive care units by amplitude integrated EEG (aEEG) and indices of background activity and sleep cycling patterns were correlated with long term outcome. We hypothesized an association between types of placental lesions and abnormal neonatal aEEG patterns.

OBJECTIVE

To determine the association between the placental lesions observed in extreme preterm deliveries, and their neonatal aEEG patterns and survival.

PATIENTS AND METHODS

This prospective cohort study included extreme premature infants, who were born ≤ 28 weeks of gestation, their placentas were available for histologic examination, and had a continues aEEG, soon after birth)n = 34). Infants and maternal clinical data were collected. aEEG data was assessed for percentage of depressed daily activity in the first 3 days of life and for sleep cycling. Associations of placental histology with clinical findings and aEEG activity were explored using parametric and non-parametric statistics.

RESULTS

Twenty two out of the 34 newborns survived to discharge. Preterm prelabor rupture of membranes (PPROM) or chorioamnionitis were associated with placental lesions consistent with fetal amniotic fluid infection (AFI) or maternal under perfusion (MUP) (P < 0.05). Lesions consistent with fetal response to AFI were associated with absence of SWC pattern during the 1st day of life. Fetal-vascular-thrombo-occlusive lesions of inflammatory type were negatively associated with depressed cerebral activity during the 1st day of life, and with aEEG cycling during the 2nd day of life (P<0.05). Placental lesions associated with MUP were associated with depressed neonatal cerebral activity during the first 3 days of life (P = 0.007).

CONCLUSIONS

Depressed neonatal aEEG patterns are associated with placental lesions consistent with maternal under perfusion, and amniotic fluid infection of fetal type, but not with fetal thrombo-oclusive vascular disease of inflammatory type. Our findings highlight the association between the intrauterine mechanisms leading to preterm parturition and subsequent depressed neonatal cerebral function early after birth, which eventually may put premature infants at risk for abnormal neurodevelopmental outcome.

Neurodevelopmental Outcome of Extremely Low Birth Weight Children at Corrected Age of Two Years

OBJECTIVE

To assess the neurodevelopmental, cognitive and behavioral function of extremely low birth weight babies (ELBW) till corrected age of two years.

METHODS

79 ELBW babies were enrolled and followed at 1 year (n=50), 18 months (n=47) and 2 years (n=36). Adverse composite outcome was defined as death or moderate-to-severe neurodevelopmental impairment (defined as either cerebral palsy or DQ score <70 or deafness or blindness).

RESULTS

At 1 year, 24% were neurologically abnormal. At 18 months, average score (>85) was seen in 25 (54%) children in motor and 8 (17%) in mental development. Abnormal behavioral score (?12) was seen in 89% children. Adverse composite outcome was present in 28 (35.4%) babies.

CONCLUSIONS

ELBW neonates are at a high risk of neurodevelopmental and behavioral impairment.