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De Dios Domínguez C, Pérez Cadena LG, Pérez Cadena MG. Does tranexamic acid reduce transfusion requirements in children with cerebral palsy undergoing osteotomies? A systematic review and meta-analysis. J Orthop 2024; 58:66-74. [PMID: 39055284 PMCID: PMC11266870 DOI: 10.1016/j.jor.2024.06.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2024] [Revised: 06/22/2024] [Accepted: 06/25/2024] [Indexed: 07/27/2024] Open
Abstract
Introduction Children with cerebral palsy have postural alterations and hip displacements are common among them, for which osteotomies must be carried out, involving great blood loss. Tranexamic acid (TXA), a fibrinolysis inhibitor, has been shown to reduce bleeding in osteotomies. However, the effectiveness of TXA in children with cerebral palsy has not been well studied, so a comprehensive meta-analysis is required to evaluate its impact. Objective We conducted a meta-analysis to investigate the effectiveness of tranexamic acid administration in reducing blood loss and transfusions during osteotomies in children with cerebral palsy. Methods Databases were searched until April 17, 2024, for randomized controlled trials and observational cohort studies comparing TXA use versus a control group. The primary outcome was overall transfusion.Secondary outcomes included intraoperative transfusion, postoperative transfusion, postoperative hemoglobin (Hb), postoperative hematocrit (Hct), drop in Hct, drop in Hb, length of stay, total blood loss (TBL) and estimated blood loss (EBL). The analysis utilized pooled relative risk ratios (RR) for categorical variables, and mean difference (MD) for numerical variables. We utilized the fixed-effects model utilizing the Mantel-Haenszel method. Results The analysis included 7 articles, which collectively provided data on 943 patients. It was found thatTXA administration decreases overall transfusion rate (RR = 0,65, 95 % CI: 0.47 to 0,90, p = 0,008),postoperative transfusion rate (RR = 0.53, 95 % CI: 0.36 to 0,79, p = 0.002) and TBL (MD = -139,41, 95 % CI: 221,34 to -57,48, p = 0,0009). There was less length of stay in the control group (MD = 0,47, 95 % CI: 0.10 to0,84, p = 0,01). TXA doesn't demonstrate significant differences in EBL, intraoperative transfusion rate, postoperative Hb, postoperative Hct, drop in Hct or drop in Hb. Conclusion TXA reduces the need of transfusion and total blood loss and increased length of hospital stay. And TXA doesn't demonstrate significant differences in EBL, intraoperative transfusion rate, postoperative Hb, postoperative Hct, drop in Hct or drop in Hb.
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Hadi E, Haddad L, Levy M, Gindes L, Hausman-Kedem M, Bassan H, Ben-Sira L, Libzon S, Kassif E, Hoffmann C, Leibovitz Z, Kasprian G, Lerman-Sagie T. Fetal intraventricular hemorrhage and periventricular hemorrhagic venous infarction: time for dedicated classification system. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2024; 64:285-293. [PMID: 38363592 DOI: 10.1002/uog.27613] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/03/2023] [Revised: 01/27/2024] [Accepted: 01/29/2024] [Indexed: 02/17/2024]
Affiliation(s)
- E Hadi
- Diagnostic Ultrasound Unit, The Institute of Obstetrical and Gynecological Imaging, Department of Obstetrics and Gynecology, Sheba Medical Center, Ramat Gan, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - L Haddad
- Fetal Neurology Clinic, Wolfson Medical Center, Holon, Israel
- Ultrasound Unit, Department of Obstetrics and Gynecology, Wolfson Medical Center, Holon, Israel
- Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - M Levy
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- The Raphael Recanati Genetics Institute, Rabin Medical Center, Beilinson Campus, Petach Tikva, Israel
| | - L Gindes
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- Fetal Neurology Clinic, Wolfson Medical Center, Holon, Israel
- Ultrasound Unit, Department of Obstetrics and Gynecology, Wolfson Medical Center, Holon, Israel
| | - M Hausman-Kedem
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- Pediatric Neurology Institute, Dana-Dwek Children's Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - H Bassan
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- Pediatric Neurology and Development Center, Shamir Medical Center (Assaf Harofeh), Be'er Ya'akov, Israel
| | - L Ben-Sira
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- Department of Radiology, Division of Pediatric Radiology, Dana Children's Hospital, Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - S Libzon
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- Fetal Neurology Clinic, Wolfson Medical Center, Holon, Israel
- Pediatric Neurology Institute, Dana-Dwek Children's Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - E Kassif
- Diagnostic Ultrasound Unit, The Institute of Obstetrical and Gynecological Imaging, Department of Obstetrics and Gynecology, Sheba Medical Center, Ramat Gan, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - C Hoffmann
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- Neuroradiology Unit, Department of Diagnostic Radiology, Sheba Medical Center, Ramat Gan, Israel
| | - Z Leibovitz
- Fetal Neurology Clinic, Wolfson Medical Center, Holon, Israel
- Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
- Obstetrics and Gynecology Ultrasound Unit, Bnai-Zion Medical Center, Haifa, Israel
| | - G Kasprian
- Department of Biomedical Imaging and Image-Guided Therapy, Division of Neuroradiology, Medical University of Vienna, Vienna, Austria
| | - T Lerman-Sagie
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- Fetal Neurology Clinic, Wolfson Medical Center, Holon, Israel
- Pediatric Neurology Unit, Wolfson Medical Center, Holon, Israel
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Fortin O, Husein N, Oskoui M, Shevell MI, Kirton A, Dunbar M. Risk Factors and Outcomes for Cerebral Palsy With Hypoxic-Ischemic Brain Injury Patterns Without Documented Neonatal Encephalopathy. Neurology 2024; 102:e208111. [PMID: 38422458 DOI: 10.1212/wnl.0000000000208111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Accepted: 11/16/2023] [Indexed: 03/02/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Perinatal hypoxic-ischemic brain injury is a leading cause of term-born cerebral palsy, the most common lifelong physical disability. Diagnosis is commonly made in the neonatal period by the combination of neonatal encephalopathy (NE) and typical neuroimaging findings. However, children without a history of neonatal encephalopathy may present later in childhood with motor disability and neuroimaging findings consistent with perinatal hypoxic-ischemic injury. We sought to determine the prevalence of such presentations using the retrospective viewpoint of a large multiregional cerebral palsy registry. METHODS Patient cases were extracted from the Canadian Cerebral Palsy Registry with gestational age >36 weeks, an MRI pattern consistent with hypoxic-ischemic injury (HII, acute total, partial prolonged, or combined), and an absence of postnatal cause for HII. Documentation of NE was noted. Maternal-fetal risk factors, labor and delivery, neonatal course, and clinical outcome were extracted. Comparisons were performed using χ2 tests and multivariable logistic regression with multiple imputation. Propensity scores were used to assess for bias. RESULTS Of the 170 children with MRI findings typical for HII, 140 (82.4%, 95% confidence interval [CI] 75.7%-87.7%) had documented NE and 29 (17.0%, 95% CI 11.7%-23.6%) did not. The group without NE had more abnormalities of amniotic fluid volume (odds ratio [OR] 15.8, 95% CI 1.2-835), had fetal growth restriction (OR 4.7, 95% CI 1.0-19.9), had less resuscitation (OR 0.03, 95% CI 0.007-0.08), had higher 5-minute Apgar scores (OR 2.2, 95% CI 1.6-3.0), were less likely to have neonatal seizures (OR 0.004, 95% CI 0.00009-0.03), and did not receive therapeutic hypothermia. MRI was performed at a median 1.1 months (interquartile range [IQR] 0.67-12.8 months) for those with NE and 12.2 months (IQR 6.6-25.9) for those without (p = 0.011). Patterns of injury on MRI were seen in similar proportions. Hemiplegia was more common in those without documented NE (OR 5.1, 95% CI 1.5-16.1); rates of preserved ambulatory function were similar. DISCUSSION Approximately one-sixth of term-born children with an eventual diagnosis of cerebral palsy and MRI findings consistent with perinatal hypoxic-ischemic brain injury do not have documented neonatal encephalopathy, which was associated with abnormalities of fetal growth and amniotic fluid volume, and a less complex neonatal course. Long-term outcomes seem comparable with their peers with encephalopathy. The absence of documented neonatal encephalopathy does not exclude perinatal hypoxic-ischemic injury, which may have occurred antenatally and must be carefully evaluated with MRI.
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Affiliation(s)
- Olivier Fortin
- From the Prenatal Pediatric Institute (O.F.), Children's National Hospital, Washington, DC; Departments of Pediatrics and Neurology/Neurosurgery (O.F., M.O., M.I.S.), McGill University; Research Institute-McGill University Health Centre (N.H., M.O., M.I.S.), Montreal, Quebec; Departments of Pediatrics and Clinical Neurosciences (A.K.); Alberta Children's Hospital Research Institute (A.K., M.D.); and Departments of Pediatrics and Community Health Sciences (M.D.), University of Calgary, Alberta
| | - Nafisa Husein
- From the Prenatal Pediatric Institute (O.F.), Children's National Hospital, Washington, DC; Departments of Pediatrics and Neurology/Neurosurgery (O.F., M.O., M.I.S.), McGill University; Research Institute-McGill University Health Centre (N.H., M.O., M.I.S.), Montreal, Quebec; Departments of Pediatrics and Clinical Neurosciences (A.K.); Alberta Children's Hospital Research Institute (A.K., M.D.); and Departments of Pediatrics and Community Health Sciences (M.D.), University of Calgary, Alberta
| | - Maryam Oskoui
- From the Prenatal Pediatric Institute (O.F.), Children's National Hospital, Washington, DC; Departments of Pediatrics and Neurology/Neurosurgery (O.F., M.O., M.I.S.), McGill University; Research Institute-McGill University Health Centre (N.H., M.O., M.I.S.), Montreal, Quebec; Departments of Pediatrics and Clinical Neurosciences (A.K.); Alberta Children's Hospital Research Institute (A.K., M.D.); and Departments of Pediatrics and Community Health Sciences (M.D.), University of Calgary, Alberta
| | - Michael I Shevell
- From the Prenatal Pediatric Institute (O.F.), Children's National Hospital, Washington, DC; Departments of Pediatrics and Neurology/Neurosurgery (O.F., M.O., M.I.S.), McGill University; Research Institute-McGill University Health Centre (N.H., M.O., M.I.S.), Montreal, Quebec; Departments of Pediatrics and Clinical Neurosciences (A.K.); Alberta Children's Hospital Research Institute (A.K., M.D.); and Departments of Pediatrics and Community Health Sciences (M.D.), University of Calgary, Alberta
| | - Adam Kirton
- From the Prenatal Pediatric Institute (O.F.), Children's National Hospital, Washington, DC; Departments of Pediatrics and Neurology/Neurosurgery (O.F., M.O., M.I.S.), McGill University; Research Institute-McGill University Health Centre (N.H., M.O., M.I.S.), Montreal, Quebec; Departments of Pediatrics and Clinical Neurosciences (A.K.); Alberta Children's Hospital Research Institute (A.K., M.D.); and Departments of Pediatrics and Community Health Sciences (M.D.), University of Calgary, Alberta
| | - Mary Dunbar
- From the Prenatal Pediatric Institute (O.F.), Children's National Hospital, Washington, DC; Departments of Pediatrics and Neurology/Neurosurgery (O.F., M.O., M.I.S.), McGill University; Research Institute-McGill University Health Centre (N.H., M.O., M.I.S.), Montreal, Quebec; Departments of Pediatrics and Clinical Neurosciences (A.K.); Alberta Children's Hospital Research Institute (A.K., M.D.); and Departments of Pediatrics and Community Health Sciences (M.D.), University of Calgary, Alberta
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Dorner RA, Boss RD, Vazifedan T, Johnson E, Garzón A, Lemmon ME. Life on the Frontlines: Caregiver Experience of Pediatric Cerebrospinal Shunt Malfunction. Pediatr Neurol 2023; 147:124-129. [PMID: 37611406 PMCID: PMC10578452 DOI: 10.1016/j.pediatrneurol.2023.07.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Revised: 04/21/2023] [Accepted: 07/26/2023] [Indexed: 08/25/2023]
Abstract
BACKGROUND We aimed to characterize the caregiver experience in the detection and evaluation of pediatric cerebrospinal shunt malfunction. METHODS In this descriptive qualitative study, we recruited English-speaking caregivers of children aged five years or less in collaboration with a stakeholder organization. Semistructured interviews were completed; content targeted the caregiver experience of shunt malfunction. Interviews were audio-recorded, transcribed, and deidentified. Qualitative data were analyzed using a conventional content analysis approach. RESULTS We enrolled 20 caregivers (n = 20 mothers). The median child age at the time of the interview was 2.8 years; about half (n = 11) were born prematurely and the majority (n = 15) had shunts placed at age less than six months. Caregiver experiences of shunt malfunction were grouped into three major themes: (1) my error could be life or death: the high stakes of shunt malfunction and the ambiguity of malfunction symptoms exacerbated baseline caregiver vigilance; (2) finding and engaging people who can help: hurdles during malfunction evaluation included locating trusted clinicians and advocating for parental intuition; and (3) how the shunt defines our family: caregivers described evolving expertise and modifications made to everyday life due to the threat of malfunction. CONCLUSIONS In this study, caregivers highlighted the challenges associated with recognizing shunt malfunction, accessing necessary treatment, and the impact of their child's shunt on family life. Future work should leverage these findings to inform counseling about shunt malfunction, develop interventions to better support families in shunt malfunction identification, and educate medical providers.
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Affiliation(s)
- Rebecca A Dorner
- Neonatal Research Institute, Sharp Mary Birch Hospital for Women & Newborns, San Diego, California.
| | - Renee D Boss
- Division of Perinatal-Neonatal Medicine, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland; Johns Hopkins University Phoebe R. Berman Institute of Bioethics, Baltimore, Maryland
| | - Turaj Vazifedan
- Department of Pediatrics, Children's Hospital of The King's Daughters, Norfolk, Virginia
| | - Erin Johnson
- Department of Pediatrics, Children's Hospital of The King's Daughters, Norfolk, Virginia
| | | | - Monica E Lemmon
- Departments of Pediatrics and Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
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Shehzad I, Raju M, Jackson I, Beeram M, Govande V, Chiruvolu A, Vora N. Evaluation of Autism Spectrum Disorder Risk in Infants With Intraventricular Hemorrhage. Cureus 2023; 15:e45541. [PMID: 37868372 PMCID: PMC10586226 DOI: 10.7759/cureus.45541] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Accepted: 09/18/2023] [Indexed: 10/24/2023] Open
Abstract
Background This study evaluates the long-term risk of autism spectrum disorder (ASD) in infants with intraventricular hemorrhage (IVH) using the Modified Checklist for Autism in Toddlers-Revised with Follow-Up (M-CHAT-R/F) screening tool. Methods This retrospective cohort study compared IVH (exposed) infants across all gestational age groups with no-IVH (non-exposed) infants admitted to level IV neonatal intensive care unit (NICU). The M-CHAT-R/F screening tool was used to assess the ASD risk at 16-30 months of age. Discharge cranial ultrasound (CUS) findings also determined the ASD risk. Descriptive statistics comprised median and interquartile range for skewed continuous data and frequencies and percentages for categorical variables. Comparisons for non-ordinal categorical measures in bivariate analysis were carried out using the χ2 test or Fisher exact test. Results Of the 334 infants, 167 had IVH, and 167 had no IVH. High ASD risk (43% vs. 20%, p = 0.044) and cerebral palsy (19% vs. 5%, p = 0.004) were significantly associated with severe IVH. Infants with CUS findings of periventricular leukomalacia had 3.24 odds of developing high ASD risk (odds ratios/OR: 3.24, 95% confidence interval/CI: 0.73-14.34), and those with hydrocephalus needing ventriculoperitoneal (VP) shunt had 4.75 odds of developing high ASD risk (OR: 4.75, 95% CI: 0.73-30.69). Conclusion Severe IVH, but not mild IVH, increased the risk of ASD and cerebral palsy. This study demonstrates the need for timely screening for ASD in high-risk infants. Prompt detection leads to earlier treatment and better outcomes.
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Affiliation(s)
- Irfan Shehzad
- Neonatology, Baylor Scott & White Health, Temple, USA
| | - Muppala Raju
- Neonatology, Baylor Scott & White Health, Temple, USA
| | | | | | | | | | - Niraj Vora
- Neonatology, Baylor Scott & White Health, Temple, USA
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Chevallier M, Barrington KJ, Terrien Church P, Luu TM, Janvier A. Decision-making for extremely preterm infants with severe hemorrhages on head ultrasound: Science, values, and communication skills. Semin Fetal Neonatal Med 2023; 28:101444. [PMID: 37150640 DOI: 10.1016/j.siny.2023.101444] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/09/2023]
Abstract
Severe intracranial hemorrhages are not rare in extremely preterm infants. They occur early, generally when babies require life-sustaining interventions. This may lead to ethical discussions and decision-making about levels of care. Prognosis is variable and depends on the extent, location, and laterality of the lesions, and, importantly also on the subsequent occurrence of other clinical complications or progressive ventricular dilatation. Decision-making should depend on prognosis and parental values. This article will review prognosis and the uncertainty of outcomes for different lesions and provide an outline of ways to conduct an ethically appropriate discussion on the decision of whether to continue life sustaining therapy. It is possible to communicate in a compassionate and honest way with parents and engage in decision-making, focussing on personalized information and decisions, and on function, as opposed to diagnosis.
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Affiliation(s)
- M Chevallier
- Department of Neonatal Intensive Care Unit, CHU Grenoble, Grenoble, France; TIMC-IMAG Research Department; Grenoble Alps University; Grenoble, France
| | - K J Barrington
- Department of Pediatrics, Université de Montréal, Montréal, Canada; Division of Neonatology, CHU Sainte-Justine Research Center, CHU Sainte-Justine, Montréal, Canada; Centre de Recherche Du CHU Sainte-Justine, Montréal, Québec, Canada
| | - P Terrien Church
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
| | - T M Luu
- Department of Pediatrics, Université de Montréal, Montréal, Canada; Centre de Recherche Du CHU Sainte-Justine, Montréal, Québec, Canada
| | - A Janvier
- Department of Pediatrics, Université de Montréal, Montréal, Canada; Division of Neonatology, CHU Sainte-Justine Research Center, CHU Sainte-Justine, Montréal, Canada; Centre de Recherche Du CHU Sainte-Justine, Montréal, Québec, Canada; Bureau de L'éthique Clinique, Université de Montréal, Canada; Unité D'éthique Clinique, Unité de Soins Palliatifs, Bureau Du Partenariat Patients-Familles-Soignants; CHU Sainte-Justine, Montréal, Canada.
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Marable CA, Roell K, Kuban K, O’Shea TM, Fry RC. Placental transcriptional signatures associated with cerebral white matter damage in the neonate. Front Neurosci 2022; 16:1017953. [PMID: 36389237 PMCID: PMC9650394 DOI: 10.3389/fnins.2022.1017953] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Accepted: 10/04/2022] [Indexed: 09/10/2023] Open
Abstract
Cerebral white matter is the most common anatomic location of neonatal brain injury in preterm newborns. Factors that predispose preterm newborns to white matter damage are understudied. In relation to studies of the placenta-brain-axis, dysregulated placental gene expression may play a role in preterm brain damage given its implication in programming early life origins of disease, including neurological disorders. There is a critical need to investigate the relationships between the placental transcriptome and white matter damage in the neonate. In a cohort of extremely low gestational age newborns (ELGANs), we aimed to investigate the relationship between the placental transcriptome and white matter damage as assessed by neonatal cranial ultrasound studies (echolucency and/or ventriculomegaly). We hypothesized that genes involved in inflammatory processes would be more highly expressed in placentas of ELGANs who developed ultrasound-defined indicators of white matter damage. Relative to either form of white matter damage, 659 placental genes displayed altered transcriptional profiles. Of these white matter damage-associated genes, largely distinct patterns of gene expression were observed in the study (n = 415/659 genes). Specifically, 381 genes were unique to echolucency and 34 genes were unique to ventriculomegaly. Pathways involved in hormone disruption and metabolism were identified among the unique echolucency or ventriculomegaly genes. Interestingly, a common set of 244 genes or 37% of all genes was similarly dysregulated in the placenta relative to both echolucency and ventriculomegaly. For this common set of white matter damage-related genes, pathways involved in inflammation, immune response and apoptosis, were enriched. Among the white matter damage-associated genes are genes known to be involved in Autism Spectrum Disorder (ASD) and endocrine system disorders. These data highlight differential mRNA expression patterning in the placenta and provide insight into potential etiologic factors that may predispose preterm newborns to white matter damage. Future studies will build upon this work to include functional measures of neurodevelopment as well as measures of brain volume later in life.
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Affiliation(s)
- Carmen Amelia Marable
- School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Kyle Roell
- Department of Environmental Sciences and Engineering, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
- Institute for Environmental Health Solutions, Gilling School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Karl Kuban
- Division of Pediatric Neurology, Department of Pediatrics, Boston University Medical Center, Boston, MA, United States
| | - T. Michael O’Shea
- Department of Pediatrics, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Rebecca C. Fry
- Department of Environmental Sciences and Engineering, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
- Institute for Environmental Health Solutions, Gilling School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
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Navidi A, De Boissieu P, Mannes I, Mokhtari M, Adamsbaum C. Periventricular hemorrhagic infarction (PVHI) associated with intraventricular hemorrhage (IVH) in premature infants: Outcome at 2 years of age. Arch Pediatr 2022; 29:459-466. [DOI: 10.1016/j.arcped.2022.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Revised: 03/22/2022] [Accepted: 05/12/2022] [Indexed: 11/26/2022]
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9
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Goeral K, Kasprian G, Hüning BM, Waldhoer T, Fuiko R, Schmidbauer V, Prayer D, Felderhoff‐Müser U, Berger A, Olischar M, Klebermass‐Schrehof K. A novel magnetic resonance imaging-based scoring system to predict outcome in neonates born preterm with intraventricular haemorrhage. Dev Med Child Neurol 2022; 64:608-617. [PMID: 34839534 PMCID: PMC9299734 DOI: 10.1111/dmcn.15116] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Revised: 10/27/2021] [Accepted: 10/28/2021] [Indexed: 11/28/2022]
Abstract
AIM To create a magnetic resonance imaging (MRI)-based scoring system specific to neonates born preterm with intraventricular haemorrhage (IVH), which could serve as a reliable prognostic indicator for later development and might allow for improved outcome prediction, individually-tailored parental counselling, and clinical decision-making. METHOD This retrospective, two-center observational cohort study included 103 infants born preterm with IVH (61 males, 42 females; median gestational age 26wks 6d), born between 2000 and 2016. Term-equivalent MRI was evaluated using a novel scoring system consisting of 11 items. A total MRI score was calculated and correlated with neurodevelopment between 2 years and 3 years of age. Prediction models for outcome were defined. RESULTS The proposed MRI scoring system showed high correlation and strong predictive ability with regard to later cognitive and motor outcome. The prediction models were translated into easy-to-use tables, allowing developmental risk assessment. INTERPRETATION The proposed MRI-based scoring system was created especially for infants born preterm with IVH and enables a comprehensive assessment of important brain areas as well as potential additional abnormalities commonly associated with IVH. Thus, it better represents the severity of brain damage when compared with the conventional IVH classification. Our scoring system should provide clinicians with valuable information, to optimize parental counselling and clinical decision-making.
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Affiliation(s)
- Katharina Goeral
- Division of Neonatology, Intensive Care and NeuropediatricsDepartment of Pediatrics and Adolescent MedicineComprehensive Center for PediatricsMedical University of ViennaViennaAustria
| | - Gregor Kasprian
- Division of Neuroradiology and Musculoskeletal RadiologyDepartment of RadiologyMedical University of ViennaViennaAustria
| | - Britta M Hüning
- Department of Pediatrics INeonatologyUniversity Children's Hospital EssenUniversity Duisburg‐EssenEssenGermany
| | - Thomas Waldhoer
- Department of EpidemiologyCenter of Public HealthMedical University of ViennaViennaAustria
| | - Renate Fuiko
- Division of Neonatology, Intensive Care and NeuropediatricsDepartment of Pediatrics and Adolescent MedicineComprehensive Center for PediatricsMedical University of ViennaViennaAustria
| | - Victor Schmidbauer
- Division of Neuroradiology and Musculoskeletal RadiologyDepartment of RadiologyMedical University of ViennaViennaAustria
| | - Daniela Prayer
- Division of Neuroradiology and Musculoskeletal RadiologyDepartment of RadiologyMedical University of ViennaViennaAustria
| | - Ursula Felderhoff‐Müser
- Department of Pediatrics INeonatologyUniversity Children's Hospital EssenUniversity Duisburg‐EssenEssenGermany
| | - Angelika Berger
- Division of Neonatology, Intensive Care and NeuropediatricsDepartment of Pediatrics and Adolescent MedicineComprehensive Center for PediatricsMedical University of ViennaViennaAustria
| | - Monika Olischar
- Division of Neonatology, Intensive Care and NeuropediatricsDepartment of Pediatrics and Adolescent MedicineComprehensive Center for PediatricsMedical University of ViennaViennaAustria
| | - Katrin Klebermass‐Schrehof
- Division of Neonatology, Intensive Care and NeuropediatricsDepartment of Pediatrics and Adolescent MedicineComprehensive Center for PediatricsMedical University of ViennaViennaAustria
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Helderman J, O’Shea TM, Dansereau L, Check J, Hofheimer JA, Smith LM, McGowan E, Neal CR, Carter BS, Pastyrnak SL, Betz B, Junewick J, Borders HL, DellaGrotta SA, Lester BM. Association of Abnormal Findings on Neonatal Cranial Ultrasound With Neurobehavior at Neonatal Intensive Care Unit Discharge in Infants Born Before 30 Weeks' Gestation. JAMA Netw Open 2022; 5:e226561. [PMID: 35394511 PMCID: PMC8994127 DOI: 10.1001/jamanetworkopen.2022.6561] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
IMPORTANCE Cranial ultrasound (CUS) findings are routinely used to identify preterm infants at risk for impaired neurodevelopment, and neurobehavioral examinations provide information about early brain function. The associations of abnormal findings on early and late CUS with neurobehavior at neonatal intensive care unit (NICU) discharge have not been reported. OBJECTIVE To examine the associations between early and late CUS findings and infant neurobehavior at NICU discharge. DESIGN, SETTING, AND PARTICIPANTS This prospective cohort study included infants enrolled in the Neonatal Neurobehavior and Outcomes in Very Preterm Infants Study between April 2014 and June 2016. Infants born before 30 weeks' gestational age were included. Exclusion criteria were maternal age younger than 18 years, maternal cognitive impairment, maternal inability to read or speak English or Spanish, maternal death, and major congenital anomalies. Overall, 704 infants were enrolled. The study was conducted at 9 university-affiliated NICUs in Providence, Rhode Island; Grand Rapids, Michigan; Kansas City, Missouri; Honolulu, Hawaii; Winston-Salem, North Carolina; and Torrance and Long Beach, California. Data were analyzed from September 2019 to September 2021. EXPOSURES Early CUS was performed at 3 to 14 days after birth and late CUS at 36 weeks' postmenstrual age or NICU discharge. Abnormal findings were identified by consensus of standardized radiologists' readings. MAIN OUTCOMES AND MEASURES Neurobehavioral examination was performed using the NICU Network Neurobehavioral Scale (NNNS). RESULTS Among the 704 infants enrolled, 675 had both CUS and NNNS data (135 [20.0%] Black; 368 [54.5%] minority race or ethnicity; 339 [50.2%] White; 376 [55.7%] male; mean [SD] postmenstrual age, 27.0 [1.9] weeks). After covariate adjustment, lower attention (adjusted mean difference, -0.346; 95% CI, -0.609 to -0.083), hypotonicity (mean difference, 0.358; 95% CI, 0.055 to 0.662), and poorer quality of movement (mean difference, -0.344; 95% CI, -0.572 to -0.116) were observed in infants with white matter damage (WMD). Lower attention (mean difference, -0.233; 95% CI, -0.423 to -0.044) and hypotonicity (mean difference, 0.240; 95% CI, 0.014 to 0.465) were observed in infants with early CUS lesions. CONCLUSIONS AND RELEVANCE In this cohort study of preterm infants, certain early CUS lesions were associated with hypotonicity and lower attention around term-equivalent age. WMD was associated with poor attention, hypotonicity, and poor quality of movement. Infants with these CUS lesions might benefit from targeted interventions to improve neurobehavioral outcomes during their NICU hospitalization.
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Affiliation(s)
- Jennifer Helderman
- Department of Pediatrics, Wake Forest School of Medicine, Winston Salem, North Carolina
| | - T. Michael O’Shea
- Department of Pediatrics/Neonatal-Perinatal Medicine, University of North Carolina School of Medicine, Chapel Hill
| | - Lynne Dansereau
- Brown Center for Children at Risk, Women and Infants Hospital of Rhode Island, Providence
| | - Jennifer Check
- Department of Pediatrics, Wake Forest School of Medicine, Winston Salem, North Carolina
| | - Julie A. Hofheimer
- Department of Pediatrics/Neonatal-Perinatal Medicine, University of North Carolina School of Medicine, Chapel Hill
| | - Lynne M. Smith
- Department of Pediatrics, Lundquist Institute at Harbor-UCLA, Torrance, California
| | - Elisabeth McGowan
- Department of Pediatrics, Brown Alpert Medical School and Women and Infants Hospital, Providence, Rhode Island
| | - Charles R. Neal
- Department of Pediatrics, University of Hawaii John A Burns School of Medicine, Honolulu
| | - Brian S. Carter
- Department of Pediatrics–Neonatology, Children’s Mercy Hospital, Kansas City, Missouri
| | - Steven L. Pastyrnak
- Department of Pediatrics, Spectrum Health–Helen DeVos Hospital, Grand Rapids, Michigan
| | - Bradford Betz
- Department of Pediatric Radiology, Spectrum Health–Helen DeVos Hospital, Grand Rapids, Michigan
| | - Joseph Junewick
- Department of Diagnostic Radiology, Spectrum Health–Helen DeVos Hospital, Grand Rapids, Michigan
| | | | - Sheri A. DellaGrotta
- Brown Center for Children at Risk, Women and Infants Hospital of Rhode Island, Providence
| | - Barry M. Lester
- Brown Center for Children at Risk, Women and Infants Hospital of Rhode Island, Providence
- Department of Psychiatry, Brown Alpert Medical School, Providence, Rhode Island
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11
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Abiramalatha T, Ramaswamy VV, Ponnala AK, Kallem VR, Murkunde YV, Punnoose AM, Vivekanandhan A, Pullattayil AK, Amboiram P. Emerging neuroprotective interventions in periventricular leukomalacia: A systematic review of preclinical studies. Expert Opin Investig Drugs 2022; 31:305-330. [PMID: 35143732 DOI: 10.1080/13543784.2022.2040479] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
INTRODUCTION Periventricular leukomalacia (PVL) is a result of various antenatal, intrapartum, or postnatal insults to the developing brain and is an important harbinger of cerebral palsy in preterm neonates. There is no proven therapy for PVL. This calls for appraisal of targeted therapies that have been investigated in animal models to evaluate their relevance in clinical research context. AREAS COVERED This systematic review identifies interventions that were evaluated in preclinical studies for neuroprotective efficacy against PVL. We identified 142 studies evaluating various interventions in PVL animal models. (Search method is detailed in section 2). EXPERT OPINION Interventions that have yielded significant results in preclinical research, and that have been evaluated in a limited number of clinical trials include stem cells, erythropoietin, and melatonin. Many other therapeutic modalities evaluated in preclinical studies have been identified, but more data on their neuroprotective potential in PVL must be garnered before they can be considered for clinical trials. Because most of the tested interventions had only a partial efficacy, a combination of interventions that could be synergistic should be investigated in future preclinical studies. Furthermore, since the nature and pattern of perinatal insults to preterm brain predisposing it to PVL are substantially variable, individualised approaches for the choice of appropriate neuroprotective interventions tailored to different sub-groups of preterm neonates should be explored.
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Affiliation(s)
- Thangaraj Abiramalatha
- Consultant Neonatologist, Kovai Medical Center and Hospital (KMCH).,Department of Pediatrics and Neonatology, KMCH Institute of Health Sciences and Research, Coimbatore, India
| | | | - Andelsivj Kumar Ponnala
- Centre for Toxicology and Developmental Research (CEFTE), Sri Ramachandra Institute of Higher Education and Research, Chennai, India
| | | | - Yogeshkumar V Murkunde
- Centre for Toxicology and Developmental Research (CEFTE), Sri Ramachandra Institute of Higher Education and Research, Chennai, India
| | - Alan Mathew Punnoose
- Department of Stem Cell Research and Regenerative Medicine, Sri Ramachandra Institute of Higher Education and Research, Chennai, India
| | | | | | - Prakash Amboiram
- Department of Neonatology, Sri Ramachandra Institute of Higher Education and Research, Chennai, India
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12
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Abstract
Individuals born extremely preterm (before 28 weeks of gestation) comprise only about 0.7% of births in the United States and an even lower proportion in other high resource countries. However, these individuals account for a disproportionate number of children with cerebral palsy, intellectual deficit, autism spectrum disorder, attention deficit hyperactivity disorder, and epilepsy. This review describes two large multiple center cohorts comprised of individuals born extremely preterm: the EPICURE cohort, recruited 1995 in the United Kingdom and the Republic of Ireland, and the Extremely Low Gestational Age Newborn (ELGAN), recruited 2002-2004 in five states in the United States. The primary focus of these studies has been neurodevelopmental disorders, but also of interest are growth, respiratory illness, and parent- and self-reported global health and well-being. Both of these studies indicate that among individuals born extremely preterm the risks of most neurodevelopmental disorders are increased. Early life factors that contribute to this risk include perinatal brain damage, some of which can be identified using neonatal head ultrasound, bronchopulmonary dysplasia, and neonatal systemic inflammation. Prenatal factors, particularly the family's socioeconomic position, also appear to contribute to risk. For most adverse outcomes, the risk is higher in males. Young adults born extremely preterm who have neurodevelopmental impairment, as compared to those without such impairment, rate their quality of life lower. However, young adults born extremely preterm who do not have neurodevelopmental impairments rate their quality of life as being similar to that of young adults born at term. Finally, we summarize the current state of interventions designed to improve the life course of extremely premature infants, with particular focus on efforts to prevent premature birth and on postnatal efforts to prevent adverse neurodevelopmental outcomes.
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Affiliation(s)
- Genevieve L Taylor
- Genevieve L Taylor MD: Department of Pediatrics, Division of Neonatal-Perinatal Medicine, University of North Carolina School of Medicine
| | - T Michael O'Shea
- T. Michael O'Shea, MD, MPH: Department of Pediatrics, Division of Neonatal-Perinatal Medicine, University of North Carolina School of Medicine.
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13
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Vohr BR, McGowan EC, Brumbaugh JE, Hintz SR. Overview of Perinatal Practices with Potential Neurodevelopmental Impact for Children Affected by Preterm Birth. J Pediatr 2022; 241:12-21. [PMID: 34673090 DOI: 10.1016/j.jpeds.2021.10.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Revised: 09/27/2021] [Accepted: 10/15/2021] [Indexed: 12/16/2022]
Affiliation(s)
- Betty R Vohr
- Department of Pediatrics, Alpert Medical School of Brown University and Women & Infants Hospital, Providence, RI.
| | - Elisabeth C McGowan
- Department of Pediatrics, Alpert Medical School of Brown University and Women & Infants Hospital, Providence, RI
| | - Jane E Brumbaugh
- Children's Center of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, MN
| | - Susan R Hintz
- Division of Neonatal and Developmental Medicine, Stanford University School of Medicine, Palo Alto, CA
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14
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Mayock DE, Gogcu S, Puia-Dumitrescu M, Shaw DWW, Wright JN, Comstock BA, Heagerty PJ, Juul SE. Association between Term Equivalent Brain Magnetic Resonance Imaging and 2-Year Outcomes in Extremely Preterm Infants: A Report from the Preterm Erythropoietin Neuroprotection Trial Cohort. J Pediatr 2021; 239:117-125.e6. [PMID: 34454953 PMCID: PMC9052881 DOI: 10.1016/j.jpeds.2021.08.040] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2021] [Revised: 08/06/2021] [Accepted: 08/20/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVES To compare the term equivalent brain magnetic resonance imaging (MRI) findings between erythropoietin (Epo) treated and placebo control groups in infants 240/7-276/7 weeks of gestational age and to assess the associations between MRI findings and neurodevelopmental outcomes at 2 years corrected age. STUDY DESIGN The association between brain abnormality scores and Bayley Scales of Infant Development, Third Edition at 2 years corrected age was explored in a subset of infants enrolled in the Preterm Erythropoietin Neuroprotection Trial. Potential risk factors for neurodevelopmental outcomes such as treatment assignment, recruitment site, gestational age, inpatient complications, and treatments were examined using generalized estimating equation models. RESULTS One hundred ten infants were assigned to Epo and 110 to placebo groups. 27% of MRI scans were rated as normal, and 60%, 10%, and 2% were rated as having mild, moderate, or severe abnormality. Brain abnormality scores did not significantly differ between the treatment groups. Factors that increased the risk of higher brain injury scores included intubation; bronchopulmonary dysplasia; retinopathy of prematurity; opioid, benzodiazepine, or antibiotic treatment >7 days; and periventricular leukomalacia or severe intraventricular hemorrhage diagnosed on cranial ultrasound. Increased global brain abnormality and white matter injury scores at term equivalent were associated with reductions in cognitive, motor, and language abilities at 2 years of corrected age. CONCLUSIONS Evidence of brain injury on brain MRIs obtained at term equivalent correlated with adverse neurodevelopmental outcomes as assessed by the Bayley Scales of Infant and Toddler Development, Third Edition at 2 years corrected age. Early Epo treatment had no effect on the MRI brain injury scores compared with the placebo group.
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Affiliation(s)
- Dennis E. Mayock
- Division of Neonatology, Department of Pediatrics, University of Washington, Seattle, WA
| | - Semsa Gogcu
- Division of Neonatology, Department of Pediatrics, Wake Forest School of Medicine, Winston-Salem, NC
| | - Mihai Puia-Dumitrescu
- Division of Neonatology, Department of Pediatrics, University of Washington, Seattle, WA
| | | | - Jason N. Wright
- Department of Radiology, University of Washington, Seattle, WA
| | | | | | - Sandra E. Juul
- Division of Neonatology, Department of Pediatrics, University of Washington, Seattle, WA
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15
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Yuan J, Cao X, Deng Y. An Exploratory Study Into a New Head Ultrasound Marker for Predicting Neurodevelopmental Outcomes in Preterm Infants. Ultrasound Q 2021; 38:43-48. [PMID: 34845178 DOI: 10.1097/ruq.0000000000000582] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
ABSTRACT Preterm infants are at risk of neurological impairments and long-term developmental delay. Head ultrasound (HUS) is a promising tool for early detection of preterm brain injury and prediction of neurodevelopmental outcomes. We performed a retrospective analysis of data of 42 preterm infants with neurodevelopmental follow-up at 12 to 24 months corrected age. Corpus callosum length (CC length) and corpus callosum-fastigium length (CCF length) were measured on the HUS scans. Motor function and communication skills were assessed using evaluation scales. Corpus callosum length and CCF length were correlated with neurodevelopmental outcomes using Spearman correlation analysis. Neither CC length nor CCF length correlated with motor developmental outcomes. On early HUS, the CCF length was negatively correlated with symbolic composite percentile ranks (Spearman ρ = -0.49, P = 0.033) and total percentile ranks (Spearman ρ = -0.545, P = 0.016). On follow-up HUS scans, the CCF length was also found to be negatively correlated with social composite raw scores and percentile ranks (Spearman ρ = -0.615, P = 0.005; and Spearman ρ = -0.64, P = 0.003, respectively), symbolic composite raw scores and percentile ranks (Spearman ρ = -0.609, P = 0.006; and Spearman ρ = -0.657, P = 0.002, respectively) and total raw scores and percentile ranks (Spearman ρ = -0.472, P = 0.041; and Spearman ρ = -0.504, P = 0.028, respectively). Corpus callosum-fastigium length measurement on serial HUS is useful in predicting cognitive and behavioral outcomes at corrected age 12 to 24 months.
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Affiliation(s)
- Jing Yuan
- Department of Neonatology, Kunshan Maternity and Children's Health Care Hospital, Kunshan, Jiangsu
| | - Xiang Cao
- Department of Neonatology, Hainan Women and Children's Medical Center, Haikou, Hainan
| | - Yingping Deng
- Department of Neonatology, Children's Hospital of Fudan University, Minghang District, Shanghai, China
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16
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Law JB, Wood TR, Gogcu S, Comstock BA, Dighe M, Perez K, Puia-Dumitrescu M, Mayock DE, Heagerty PJ, Juul SE. Intracranial Hemorrhage and 2-Year Neurodevelopmental Outcomes in Infants Born Extremely Preterm. J Pediatr 2021; 238:124-134.e10. [PMID: 34217769 PMCID: PMC8551011 DOI: 10.1016/j.jpeds.2021.06.071] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Revised: 05/26/2021] [Accepted: 06/25/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVES To determine the incidence, timing, progression, and risk factors for intracranial hemorrhage (ICH) in infants 240/7 to 276/7 weeks of gestational age and to characterize the association between ICH and death or neurodevelopmental impairment (NDI) at 2 years of corrected age. STUDY DESIGN Infants enrolled in the Preterm Erythropoietin Neuroprotection Trial had serial cranial ultrasound scans performed on day 1, day 7-9, and 36 weeks of postmenstrual age to evaluate ICH. Potential risk factors for development of ICH were examined. Outcomes included death or severe NDI as well as Bayley Scales of Infant and Toddler Development, 3rd Edition, at 2 years of corrected age. RESULTS ICH was identified in 38% (n = 339) of 883 enrolled infants. Multiple gestation and cesarean delivery reduced the risk of any ICH on day 1. Risk factors for development of bilateral Grade 2, Grade 3, or Grade 4 ICH at day 7-9 included any ICH at day 1; 2 or more doses of prenatal steroids decreased risk. Bilateral Grade 2, Grade 3, or Grade 4 ICH at 36 weeks were associated with previous ICH at day 7-9. Bilateral Grade 2, any Grade 3, and any Grade 4 ICH at 7-9 days or 36 weeks of postmenstrual age were associated with increased risk of death or severe NDI and lower Bayley Scales of Infant and Toddler Development, 3rd Edition, scores. CONCLUSIONS Risk factors for ICH varied by timing of bleed. Bilateral and increasing grade of ICH were associated with death or NDI in infants born extremely preterm.
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Affiliation(s)
- Janessa B Law
- Division of Neonatology, Department of Pediatrics,
University of Washington, Seattle, WA
| | - Thomas R. Wood
- Division of Neonatology, Department of Pediatrics,
University of Washington, Seattle, WA
| | - Semsa Gogcu
- Division of Neonatology, Department of Pediatrics, Wake
Forest School of Medicine, NC
| | | | - Manjiri Dighe
- Department of Radiology, University of Washington, Seattle,
WA
| | - Krystle Perez
- Division of Neonatology, Department of Pediatrics,
University of Washington, Seattle, WA
| | - Mihai Puia-Dumitrescu
- Division of Neonatology, Department of Pediatrics,
University of Washington, Seattle, WA
| | - Dennis E. Mayock
- Division of Neonatology, Department of Pediatrics,
University of Washington, Seattle, WA
| | | | - Sandra E. Juul
- Division of Neonatology, Department of Pediatrics,
University of Washington, Seattle, WA
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17
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Campbell H, Check J, Kuban KCK, Leviton A, Joseph RM, Frazier JA, Douglass LM, Roell K, Allred EN, Fordham LA, Hooper SR, Jara H, Paneth N, Mokrova I, Ru H, Santos HP, Fry RC, O’Shea TM. Neonatal Cranial Ultrasound Findings among Infants Born Extremely Preterm: Associations with Neurodevelopmental Outcomes at 10 Years of Age. J Pediatr 2021; 237:197-205.e4. [PMID: 34090894 PMCID: PMC8478718 DOI: 10.1016/j.jpeds.2021.05.059] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Revised: 05/27/2021] [Accepted: 05/28/2021] [Indexed: 12/23/2022]
Abstract
OBJECTIVE To examine the association between neonatal cranial ultrasound (CUS) abnormalities among infants born extremely preterm and neurodevelopmental outcomes at 10 years of age. STUDY DESIGN In a multicenter birth cohort of infants born at <28 weeks of gestation, 889 of 1198 survivors were evaluated for neurologic, cognitive, and behavioral outcomes at 10 years of age. Sonographic markers of white matter damage (WMD) included echolucencies in the brain parenchyma and moderate to severe ventricular enlargement. Neonatal CUS findings were classified as intraventricular hemorrhage (IVH) without WMD, IVH with WMD, WMD without IVH, and neither IVH nor WMD. RESULTS WMD without IVH was associated with an increased risk of cognitive impairment (OR 3.5, 95% CI 1.7, 7.4), cerebral palsy (OR 14.3, 95% CI 6.5, 31.5), and epilepsy (OR 6.9; 95% CI 2.9, 16.8). Similar associations were found for WMD accompanied by IVH. Isolated IVH was not significantly associated these outcomes. CONCLUSIONS Among children born extremely preterm, CUS abnormalities, particularly those indicative of WMD, are predictive of neurodevelopmental impairments at 10 years of age. The strongest associations were found with cerebral palsy.
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Affiliation(s)
- Heather Campbell
- Department of Pediatrics, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC
| | - Jennifer Check
- Department of Pediatrics, Wake Forest University School of Medicine, Winston-Salem, NC
| | - Karl C. K. Kuban
- Department of Pediatrics, Division of Pediatric Neurology, Boston University Medical Center, Boston, MA
| | - Alan Leviton
- Department of Neurology, Boston Children’s Hospital and Harvard Medical School, Boston, MA
| | - Robert M Joseph
- Department of Anatomy and Neurobiology, Boston University School of Medicine, Boston, MA
| | - Jean A. Frazier
- Eunice Kennedy Shriver Center, University of Massachusetts Medical School, Worcester, MA
| | - Laurie M. Douglass
- Department of Pediatrics, Division of Pediatric Neurology, Boston University Medical Center, Boston, MA
| | - Kyle Roell
- Department of Pediatrics, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC
| | - Elizabeth N. Allred
- Department of Neurology, Boston Children’s Hospital and Harvard Medical School, Boston, MA
| | - Lynn Ansley Fordham
- Department of Radiology, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC
| | - Stephen R. Hooper
- Department of Allied Health, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC
| | - Hernan Jara
- Department of Radiology, Boston University Medical Center, Boston, MA
| | - Nigel Paneth
- Michigan State University College of Human Medicine, East Lansing, MI
| | | | - Hongyu Ru
- Department of Pediatrics, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC
| | - Hudson P. Santos
- Biobehavioral Laboratory, School of Nursing, University of North Carolina, Chapel Hill, NC
| | - Rebecca C. Fry
- Department of Environmental Sciences and Engineering, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC
| | - T. Michael O’Shea
- Department of Pediatrics, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC
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18
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McCauley KE, Carey EC, Weaver AL, Mara KC, Clark RH, Carey WA, Collura CA. Survival of Ventilated Extremely Premature Neonates With Severe Intraventricular Hemorrhage. Pediatrics 2021; 147:e20201584. [PMID: 33727247 PMCID: PMC8015160 DOI: 10.1542/peds.2020-1584] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/13/2020] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Severe intraventricular hemorrhage (IVH) is a leading mortality risk factor among extremely premature neonates. Because other life-threatening conditions also occur in this population, it is unclear whether severe IVH is independently associated with death. The existence and potential implications of regional variation in severe IVH-associated mortality are unknown. METHODS We performed a retrospective cohort study of mechanically ventilated neonates born at 22 to 29 weeks' gestation who received care in 242 American NICUs between 2000 and 2014. After building groups composed of propensity score-matched and center-matched pairs, we used the Cox proportional hazards analysis to test our hypothesis that severe IVH would be associated with greater all-cause in-hospital mortality, defined as death before transfer or discharge. We also performed propensity score-matched subgroup analyses, comparing severe IVH-associated mortality among 4 geographic regions of the United States. RESULTS In our analysis cohort, we identified 4679 patients with severe IVH. Among 2848 matched pairs, those with severe IVH were more likely to die compared with those without severe IVH (hazard ratio 2.79; 95% confidence interval 2.49-3.11). Among 1527 matched pairs still hospitalized at 30 days, severe IVH was associated with greater risk of death (hazard ratio 2.03; 95% confidence interval 1.47-2.80). Mortality associated with severe IVH varied substantially between geographic regions. CONCLUSIONS The early diagnosis of severe IVH is independently associated with all-cause in-hospital mortality in extremely premature neonates. Regional variation in severe IVH-associated mortality suggests that shared decision-making between parents and neonatologists is strongly influenced by ultrasound-based IVH assessment and classification.
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Affiliation(s)
| | | | - Amy L Weaver
- Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota; and
| | - Kristin C Mara
- Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota; and
| | - Reese H Clark
- Center for Research, Education and Quality, Pediatrix Medical Group, Sunrise, Florida
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19
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Banihani R, Seesahai J, Asztalos E, Terrien Church P. Neuroimaging at Term Equivalent Age: Is There Value for the Preterm Infant? A Narrative Summary. CHILDREN (BASEL, SWITZERLAND) 2021; 8:227. [PMID: 33809745 PMCID: PMC8002329 DOI: 10.3390/children8030227] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Revised: 03/10/2021] [Accepted: 03/10/2021] [Indexed: 11/17/2022]
Abstract
Advances in neuroimaging of the preterm infant have enhanced the ability to detect brain injury. This added information has been a blessing and a curse. Neuroimaging, particularly with magnetic resonance imaging, has provided greater insight into the patterns of injury and specific vulnerabilities. It has also provided a better understanding of the microscopic and functional impacts of subtle and significant injuries. While the ability to detect injury is important and irresistible, the evidence for how these injuries link to specific long-term outcomes is less clear. In addition, the impact on parents can be profound. This narrative summary will review the history and current state of brain imaging, focusing on magnetic resonance imaging in the preterm population and the current state of the evidence for how these patterns relate to long-term outcomes.
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Affiliation(s)
- Rudaina Banihani
- Newborn & Developmental Paediatrics, Sunnybrook Health Science Centre, 2075 Bayview Ave, The University of Toronto, Toronto, ON M4N 3M5, Canada; (J.S.); (E.A.); (P.T.C.)
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20
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Bangma JT, Hartwell H, Santos HP, O'Shea TM, Fry RC. Placental programming, perinatal inflammation, and neurodevelopment impairment among those born extremely preterm. Pediatr Res 2021; 89:326-335. [PMID: 33184498 PMCID: PMC7658618 DOI: 10.1038/s41390-020-01236-1] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 09/02/2020] [Accepted: 10/08/2020] [Indexed: 01/30/2023]
Abstract
Individuals born extremely preterm are at significant risk for impaired neurodevelopment. After discharge from the neonatal intensive care, associations between the child's well-being and factors in the home and social environment become increasingly apparent. Mothers' prenatal health and socioeconomic status are associated with neurodevelopmental outcomes, and emotional and behavioral problems. Research on early life risk factors and on mechanisms underlying inter-individual differences in neurodevelopment later in life can inform the design of personalized approaches to prevention. Here, we review early life predictors of inter-individual differences in later life neurodevelopment among those born extremely preterm. Among biological mechanisms that mediate relationships between early life predictors and later neurodevelopmental outcomes, we highlight evidence for disrupted placental processes and regulated at least in part via epigenetic mechanisms, as well as perinatal inflammation. In relation to these mechanisms, we focus on four prenatal antecedents of impaired neurodevelopment, namely, (1) fetal growth restriction, (2) maternal obesity, (3) placental microorganisms, and (4) socioeconomic adversity. In the future, this knowledge may inform efforts to detect and prevent adverse outcomes in infants born extremely preterm. IMPACT: This review highlights early life risk factors and mechanisms underlying inter-individual differences in neurodevelopment later in life. The review emphasizes research on early life risk factors (fetal growth restriction, maternal obesity, placental microorganisms, and socioeconomic adversity) and on mechanisms (disrupted placental processes and perinatal inflammation) underlying inter-individual differences in neurodevelopment later in life. The findings highlighted here may inform efforts to detect and prevent adverse outcomes in infants born extremely preterm.
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Affiliation(s)
- Jacqueline T Bangma
- Department of Environmental Sciences and Engineering, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Hadley Hartwell
- Department of Environmental Sciences and Engineering, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Hudson P Santos
- Biobehavioral Laboratory, School of Nursing, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Institute for Environmental Health Solutions, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - T Michael O'Shea
- Department of Pediatrics, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Rebecca C Fry
- Biobehavioral Laboratory, School of Nursing, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
- Institute for Environmental Health Solutions, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
- Curriculum in Toxicology and Environmental Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
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Bennett JF, Andrews M, Omura J. Cerebral Palsy. PHYSICIAN ASSISTANT CLINICS 2020. [DOI: 10.1016/j.cpha.2020.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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KHURANA SONIA, KANE AUDREYE, BROWN SHAARONE, TARVER TALICIA, DUSING STACEYC. Effect of neonatal therapy on the motor, cognitive, and behavioral development of infants born preterm: a systematic review. Dev Med Child Neurol 2020; 62:684-692. [PMID: 32077096 PMCID: PMC7920849 DOI: 10.1111/dmcn.14485] [Citation(s) in RCA: 48] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/31/2019] [Indexed: 12/15/2022]
Abstract
AIM To synthesize the existing literature and determine the efficacy of neonatal therapy, starting in the neonatal intensive care unit (NICU), on the motor, cognitive, and behavioral outcomes of infants born preterm. METHOD Databases were searched for randomized controlled trials or quasi-randomized controlled trials of direct therapy early intervention for infants with a gestational age of less than 37 weeks, initiated in the NICU and delivered by a therapist or parent with therapist support. Quality was evaluated using the Cochrane standardized risk of bias assessment tool. Recommendations were made using the Grading of Recommendations, Assessment, Development and Evaluations approach. RESULTS Fifteen studies met the inclusion criteria. Studies were categorized into four intervention categories: (1) parent-delivered motor intervention (PDMI); (2) therapist-delivered postural control intervention (TDPCI); (3) developmental care; and (4) oromotor intervention. Risk of bias varied from low (10 studies) to high (three studies) or was unclear (two studies). INTERPRETATION Preliminary support indicates that daily PDMI improves motor and cognitive outcomes in the short-term and possibly long-term. TDPCI is effective in promoting short-term gains in motor development. Developmental care programs designed by a neonatal therapist appear to be effective in improving short-term behavior but are inconclusive for motor and cognitive outcomes or long-term behavioral outcomes. Regarding oromotor interventions, there is insufficient research to be confident in their efficacy on improving developmental outcomes. WHAT THIS PAPER ADDS Parent-delivered motor interventions (PDMIs) are more effective in improving motor and cognitive outcomes than other interventions. Preliminary support indicates that daily PDMI improves motor and cognitive outcomes in the short- and possibly long-term. Therapist-delivered postural control interventions are effective in promoting short-term gains in motor development. Developmental care programs designed by a neonatal therapist are effective in improving the short-term behavior of infants born preterm. Oral motor interventions were found to have no effect on improving developmental outcomes.
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Affiliation(s)
- SONIA KHURANA
- Motor Development Lab, Department of Physical Therapy, College of Health Professions, Virginia Commonwealth University, Richmond, Virginia
| | - AUDREY E KANE
- Department of Occupational Therapy, College of Health Professions, Virginia Commonwealth University, Richmond, Virginia
| | - SHAARON E BROWN
- Physical Therapy Department, Virginia Commonwealth University Health, Children’s Hospital of Richmond at Virginia Commonwealth University, Richmond, Virginia
| | - TALICIA TARVER
- Tompkins-McCaw Library for the Health Sciences, Virginia Commonwealth University Libraries, Richmond, Virginia, USA
| | - STACEY C DUSING
- Motor Development Lab, Department of Physical Therapy, College of Health Professions, Virginia Commonwealth University, Richmond, Virginia
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Dusing SC, Burnsed JC, Brown SE, Harper AD, Hendricks-Munoz KD, Stevenson RD, Thacker LR, Molinini RM. Efficacy of Supporting Play Exploration and Early Development Intervention in the First Months of Life for Infants Born Very Preterm: 3-Arm Randomized Clinical Trial Protocol. Phys Ther 2020; 100:1343-1352. [PMID: 32329778 PMCID: PMC7439229 DOI: 10.1093/ptj/pzaa077] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Revised: 11/21/2019] [Accepted: 04/16/2020] [Indexed: 11/13/2022]
Abstract
OBJECTIVE The aim of this project is to study the effect of a physical therapist intervention provided in the first months of life on developmental outcomes of infants born very preterm. Secondary aims are to investigate the impact of intervention timing on the efficacy and impact of the intervention on infants with and without cerebral palsy. METHODS This study is a multisite longitudinal controlled trial comparing developmental outcomes from infants in the Supporting Play, Exploration, and Early Development Intervention (SPEEDI)_Late or SPEEDI_Early group to a usual care group. SETTINGS ARE URBAN Urban and rural areas surrounding 2 academic medical centers. There will be 90 preterm infants enrolled in this study born at <29 weeks of gestation. SPEEDI is a developmental intervention provided by collaboration between a physical therapist and parent to support a child's motor and cognitive development. The primary outcome measure is the Bayley Scale of Infant and Toddler Development Cognitive and Gross Motor Scaled Scores. Secondary measures include behavioral coding of early problem solving skills, the Gross Motor Function Measure, and Test of Infant Motor Performance. IMPACT More than 270,000 infants are born very preterm in the United States each year, 50% of whom will have neurological dysfunction that limits their ability to keep pace with peers who are typically developing. This study is a step toward understanding the impact that intensive developmental intervention could have in this population in the first months of life.
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Affiliation(s)
- Stacey C Dusing
- Biokinesiology and Physical Therapy, University of Southern California, 1540 E Alcazar St, CHP 155, Los Angeles, CA 90033 (USA),Address all correspondence to Dr. Dusing at: Dr. Dusing is a Board-Certified Clinical Specialist in Pediatric Physical Therapy.
| | - Jennifer C Burnsed
- Department of Pediatrics and Neurology, University of Virginia, Charlottesville, Virginia
| | - Shaaron E Brown
- Board Certified Pediatric Specialist, Department of Physical Therapy, Virginia Commonwealth University Health, Richmond, Virginia
| | - Amy D Harper
- Department of Neurology, Virginia Commonwealth University
| | | | | | - Leroy R Thacker
- Department of Biostatistics, Virginia Commonwealth University
| | - Rebecca M Molinini
- Rehabilitation Movement Sciences Program and Motor Development Lab, Virginia Commonwealth University
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Khazanchi R, Lyden ER, Peeples ES. Reevaluating 30-day head ultrasound screening for preterm infants in the era of decreasing periventricular leukomalacia. J Matern Fetal Neonatal Med 2020; 35:907-913. [PMID: 32146832 DOI: 10.1080/14767058.2020.1733521] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Objective: Neonatal brain injury is a potentially devastating cause of neurodevelopmental impairment. There is no consensus, however, on the appropriate timing and frequency of routine head ultrasound (HUS) screening for such injuries. We evaluated the diagnostic utility of routine HUS screening at 30 days of life ("late HUS") for detecting severe intraventricular hemorrhage (IVH) or cystic periventricular leukomalacia (c-PVL) in preterm infants with a negative HUS before 14 days of life ("early HUS").Methods: Single-center retrospective cohort analysis of infants born at ≤ 32 weeks gestational age (GA) admitted to the University of Nebraska Medical Center NICU from 2011-2018. Demographics, HUS and MRI diagnoses were abstracted from clinical records. Fisher's exact test and t-test assessed associations between categorical and continuous variable, respectively.Results: 205 infants were included-120 very preterm (28-32 weeks GA) and 85 extremely preterm (<28 weeks GA). Negative predictive value of early HUS for predicting any clinically significant anomalies (severe IVH or c-PVL) on late HUS was 100% for extremely and 99.2% for very preterm infants. Term-equivalent MRI detected previously undiagnosed c-PVL in 16.7% of the 24 patients that received MRI; all infants with new c-PVL on MRI had severe IVH on early HUS.Conclusion: Following negative early HUS, late HUS detected significant new abnormalities in one infant. These data suggest that in a unit with low prevalence of c-PVL, 30-day HUS may have limited clinical utility following negative screening. In infants with abnormal early HUS, clinicians should consider obtaining term-equivalent MRI screening to detect c-PVL.
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Affiliation(s)
- Rohan Khazanchi
- College of Medicine, University of Nebraska Medical Center, Omaha, NE, USA
| | - Elizabeth R Lyden
- Department of Biostatistics, College of Public Health, University of Nebraska Medical Center, Omaha, NE, USA
| | - Eric S Peeples
- Division of Neonatology, Department of Pediatrics, University of Nebraska Medical Center, Omaha, NE, USA
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Neurocognitive and social-communicative function of children born very preterm at 10 years of age: Associations with microorganisms recovered from the placenta parenchyma. J Perinatol 2020; 40:306-315. [PMID: 31624322 PMCID: PMC6985019 DOI: 10.1038/s41372-019-0505-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Revised: 07/18/2019] [Accepted: 08/01/2019] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Infection of the placenta has been associated with preterm birth as well as neurocognitive impairment. This study aimed to determine whether specific bacterial species in the placenta of extremely preterm pregnancies are associated with neurological deficits later in life. STUDY DESIGN Using data from 807 children in the ELGAN study the risks of a low score on six neurological assessments in relation to 15 different microbes were quantified with odds ratios. RESULTS The presence of certain microbial species in the placenta was associated with lower scores on numerical and oral language assessments. Lactobacillus sp. was associated with decreased risk of a low oral language score and a composite measure of IQ and executive function. CONCLUSION Placental microorganisms were associated with neurocognitive, but not social-communicative, outcomes at age 10. In contrast, the presence of the anti-inflammatory Lactobacillus sp. in the placenta was associated with a lower risk of impaired neurocognitive functions.
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Bangma JT, Kwiatkowski E, Psioda M, Santos HP, Hooper SR, Douglass L, Joseph RM, Frazier JA, Kuban KCK, O'Shea TM, Fry RC. Early life antecedents of positive child health among 10-year-old children born extremely preterm. Pediatr Res 2019; 86:758-765. [PMID: 31005057 PMCID: PMC6802282 DOI: 10.1038/s41390-019-0404-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Revised: 04/01/2019] [Accepted: 04/07/2019] [Indexed: 12/25/2022]
Abstract
BACKGROUND To identify modifiable antecedents during pre-pregnancy and pregnancy windows associated with a positive child health at 10 years of age. METHODS Data on 889 children enrolled in the Extremely Low Gestational Age Newborn (ELGAN) study in 2002-2004 were analyzed for associations between potentially modifiable maternal antecedents during pre-pregnancy and pregnancy time windows and a previously described positive child health index (PCHI) score at 10 years of age. Stratification by race was also investigated for associations with investigated antecedents. RESULTS Factors associated with higher PCHI (more positive health) included greater gestational age, birth weight, multiple gestation, and medical interventions, including assisted reproduction and cervical cerclage. Factors associated with lower PCHI included correlates of lower socioeconomic status, pre-pregnancy chronic medical disorders in the mother such as pre-pregnancy body mass index (BMI), and maternal asthma. When stratified by race, variation in significant results was observed. CONCLUSIONS Among children born extremely preterm, medical interventions and higher socioeconomic status were associated with improved PCHI, while chronic illness and high BMI in the mother is associated with lower PCHI at 10 years of age. Knowledge of such antecedent factors could inform efforts to develop interventions that promote positive child health outcomes in future pregnancies.
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Affiliation(s)
- Jacqueline T Bangma
- Department of Environmental Sciences and Engineering, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
| | - Evan Kwiatkowski
- Department of Biostatistics, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Matt Psioda
- Department of Biostatistics, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Hudson P Santos
- School of Nursing, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Stephen R Hooper
- Department of Allied Health Sciences, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Laurie Douglass
- Department of Pediatrics, Boston Medical Center, Boston, MA, USA
| | - Robert M Joseph
- Department of Anatomy and Neurobiology, Boston University School of Medicine, Boston, MA, USA
| | - Jean A Frazier
- Eunice Kennedy Shriver Center, Department of Psychiatry, University of Massachusetts Medical School/University of Massachusetts Memorial Health Care, Worcester, MA, USA
| | - Karl C K Kuban
- Department of Pediatrics, Division of Pediatric Neurology, Boston University Medical Center, Boston, MA, USA
| | - Thomas M O'Shea
- Department of Pediatrics, University of North Carolina, Chapel Hill, NC, USA
| | - Rebecca C Fry
- Department of Environmental Sciences and Engineering, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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"STEP", an early developmental screening tool that predicts one-year outcomes. J Perinatol 2019; 39:153-155. [PMID: 30546059 DOI: 10.1038/s41372-018-0293-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Revised: 11/19/2018] [Accepted: 11/27/2018] [Indexed: 11/08/2022]
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28
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Hortensius LM, Dijkshoorn ABC, Ecury-Goossen GM, Steggerda SJ, Hoebeek FE, Benders MJNL, Dudink J. Neurodevelopmental Consequences of Preterm Isolated Cerebellar Hemorrhage: A Systematic Review. Pediatrics 2018; 142:peds.2018-0609. [PMID: 30341153 DOI: 10.1542/peds.2018-0609] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/10/2018] [Indexed: 11/24/2022] Open
Abstract
CONTEXT The effect of neonatal cerebellar hemorrhage on neurodevelopmental outcome (NDO) in the absence of supratentorial injury is still largely unknown. OBJECTIVE To evaluate the influence of isolated neonatal cerebellar hemorrhage on cognitive, motor, language, and behavioral NDOs and assess the effect of location and size on outcome. DATA SOURCES Embase, Medline, and Scopus were searched from inception to September 30, 2017. STUDY SELECTION Studies in which a diagnosis of isolated cerebellar hemorrhage was reported in preterm infants (<32 weeks' gestation) with a standardized NDO at ≥12 months of age were included. DATA EXTRACTION Patient characteristics, location, and size of bleeding and NDO (defined as severe [yes or no] on the basis of given cutoff points) in 4 domains were extracted. RESULTS Of the 1519 studies identified, 8 were included in final analyses. Of infants with isolated cerebellar hemorrhage, 128 were described (cumulative incidence: 2.3%). The incidence of severe delay in cognition, motor, language, and behavioral development was 38%, 39%, 41%, and 38%, respectively. The overall incidence of severe neurodevelopmental delay in ≥1 domain ranged from 43% to 75% and was most seen in infants with vermis involvement (87%-93%) and with large bleeds (46%-82%). LIMITATIONS Different neurodevelopmental scales lead to data heterogeneity, and reporting of data on a group level limited possibilities for an outcome description on an individual level. CONCLUSIONS Of infants with isolated cerebellar hemorrhage, 43% to 75% were severely delayed in cognition, motor, language, and/or behavioral development, with the highest incidence with vermis involvement and with large bleeds.
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Affiliation(s)
| | | | | | - Sylke J Steggerda
- Department of Neonatology, Leiden University Medical Center, Leiden, Netherlands; and
| | - Freek E Hoebeek
- Laboratory of Neuroimmunology and Developmental Origins of Disease, Wilhelmina Children's Hospital and Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands.,Department of Neuroscience, Erasmus University Medical Center, Rotterdam, Netherlands
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Preterm neuroimaging and neurodevelopmental outcome: a focus on intraventricular hemorrhage, post-hemorrhagic hydrocephalus, and associated brain injury. J Perinatol 2018; 38:1431-1443. [PMID: 30166622 PMCID: PMC6215507 DOI: 10.1038/s41372-018-0209-5] [Citation(s) in RCA: 58] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2018] [Revised: 07/23/2018] [Accepted: 08/06/2018] [Indexed: 12/29/2022]
Abstract
Intraventricular hemorrhage in the setting of prematurity remains the most common cause of acquired hydrocephalus. Neonates with progressive post-hemorrhagic hydrocephalus are at risk for adverse neurodevelopmental outcomes. The goal of this review is to describe the distinct and often overlapping types of brain injury in the preterm neonate, with a focus on neonatal hydrocephalus, and to connect injury on imaging to neurodevelopmental outcome risk. Head ultrasound and magnetic resonance imaging findings are described separately. The current state of the literature is imprecise and we end the review with recommendations for future radiologic and neurodevelopmental research.
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30
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Hay K, Nelin M, Carey H, Chorna O, Moore-Clingenpeel M, Maitre N. Hammersmith Infant Neurological Examination Asymmetry Score Distinguishes Hemiplegic Cerebral Palsy From Typical Development. Pediatr Neurol 2018; 87:70-74. [PMID: 30190180 PMCID: PMC6320694 DOI: 10.1016/j.pediatrneurol.2018.07.002] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2018] [Accepted: 07/08/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND The Hammersmith Infant Neurological Examination is one of several useful tools for early identification of cerebral palsy; however, cut-off scores for cerebral palsy do not consistently distinguish infants with hemiplegia from those typically developing. We hypothesized that use of an asymmetry score, in addition to the assessment's standard total cutoff score, could remedy this problem in a clinical setting. METHODS This retrospective study of a neonatal intensive care follow-up program with consistent clinical use of the Hammersmith Infant Neurological Examination matched infants with a diagnosis of cerebral palsy to infants without motor delays or evidence of neurodevelopmental impairments. Groups had same corrected and gestational ages at Hammersmith Infant Neurological Examination assessment. Asymmetry presence was recorded. RESULTS Of 74 infants with cerebral palsy, 28 had quadriplegia, 11 had diplegia, and 35 had hemiplegia. Median total Hammersmith Infant Neurological Examination and asymmetry scores for hemiplegia were 57.5 and 10 versus 76 and 0 for those without cerebral palsy. Sensitivity and specificity to distinguish hemiplegia from typical development by combining a total Hammersmith Infant Neurological Examination score less than 63 and an asymmetry score greater than 5 were 91.8% and 100%, respectively. CONCLUSIONS In a clinical setting, combining total Hammersmith Infant Neurological Examination and asymmetry scores can help providers differentiate infants with hemiplegia from those typically developing.
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Affiliation(s)
- Krystal Hay
- Center for Perinatal Research and Department of Pediatrics at Nationwide Children’s Hospital, Columbus, OH
| | - MaryAnn Nelin
- Center for Perinatal Research and Department of Pediatrics at Nationwide Children’s Hospital, Columbus, OH
| | - Helen Carey
- Center for Perinatal Research and Department of Pediatrics at Nationwide Children’s Hospital, Columbus, OH
| | - Olena Chorna
- Center for Perinatal Research and Department of Pediatrics at Nationwide Children’s Hospital, Columbus, OH
| | - Melissa Moore-Clingenpeel
- Center for Perinatal Research and Department of Pediatrics at Nationwide Children’s Hospital, Columbus, OH
| | - Nathalie Maitre
- Center for Perinatal Research and Department of Pediatrics at Nationwide Children's Hospital, Columbus, Ohio; Department of Hearing and Speech Sciences, Vanderbilt Kennedy Center, Nashville, Tennessee.
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Burnett AC, Cheong JLY, Doyle LW. Biological and Social Influences on the Neurodevelopmental Outcomes of Preterm Infants. Clin Perinatol 2018; 45:485-500. [PMID: 30144851 DOI: 10.1016/j.clp.2018.05.005] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Although very preterm birth and very low birthweight are recognized risk factors for longer term developmental difficulties, there is a wide spectrum of outcomes for children and adolescents born preterm. Biological and social variables have the potential to explain this variability. Although current understanding of these influences and how they interact is incomplete, perinatal factors are related to permanent neurosensory impairments such as cerebral palsy, blindness, and deafness. Cognitive and academic outcomes are variably associated with biological and social variables across development, and the most robust correlates of behavior and mental health difficulties include early behavioral problems and family influences.
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Affiliation(s)
- Alice C Burnett
- Premature Infant Follow-Up Program, The Royal Women's Hospital, 20 Flemington Road, Parkville, Victoria 3052, Australia; Victorian Infant Brain Studies, Murdoch Childrens Research Institute, Flemington Road, Parkville, Melbourne, Victoria 3052, Australia; Department of Pediatrics, University of Melbourne, Parkville, Victoria 3010, Australia; Department of Neonatal Medicine, The Royal Children's Hospital, 50 Flemington Road, Parkville, Victoria 3052, Australia.
| | - Jeanie L Y Cheong
- Premature Infant Follow-Up Program, The Royal Women's Hospital, 20 Flemington Road, Parkville, Victoria 3052, Australia; Victorian Infant Brain Studies, Murdoch Childrens Research Institute, Flemington Road, Parkville, Melbourne, Victoria 3052, Australia; Department of Obstetrics and Gynaecology, University of Melbourne, Parkville, Victoria 3010, Australia; Neonatal Services, The Royal Women's Hospital, 20 Flemington Road, Parkville, Victoria 3052, Australia; Newborn Research, The Royal Women's Hospital, Level 7, 20 Flemington Road, Parkville, Melbourne, Victoria 3052, Australia
| | - Lex W Doyle
- Premature Infant Follow-Up Program, The Royal Women's Hospital, 20 Flemington Road, Parkville, Victoria 3052, Australia; Victorian Infant Brain Studies, Murdoch Childrens Research Institute, Flemington Road, Parkville, Melbourne, Victoria 3052, Australia; Department of Pediatrics, University of Melbourne, Parkville, Victoria 3010, Australia; Department of Obstetrics and Gynaecology, University of Melbourne, Parkville, Victoria 3010, Australia; Newborn Research, The Royal Women's Hospital, Level 7, 20 Flemington Road, Parkville, Melbourne, Victoria 3052, Australia
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Dusing SC, Tripathi T, Marcinowski EC, Thacker LR, Brown LF, Hendricks-Muñoz KD. Supporting play exploration and early developmental intervention versus usual care to enhance development outcomes during the transition from the neonatal intensive care unit to home: a pilot randomized controlled trial. BMC Pediatr 2018; 18:46. [PMID: 29426320 PMCID: PMC5809115 DOI: 10.1186/s12887-018-1011-4] [Citation(s) in RCA: 52] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2017] [Accepted: 01/25/2018] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND While therapy services may start in the Neonatal Intensive Care Unit (NICU) there is often a gap in therapy after discharge. Supporting Play Exploration and Early Development Intervention (SPEEDI) supports parents, helping them build capacity to provide developmentally supportive opportunities starting in the NICU and continuing at home. The purpose of this single blinded randomized pilot clinical trial was to evaluate the initial efficacy of SPEEDI to improve early reaching and exploratory problem solving behaviors. METHODS Fourteen infants born very preterm or with neonatal brain injury were randomly assigned to SPEEDI or Usual Care. The SPEEDI group participated in 5 collaborative parent, therapist, and infant interventions sessions in the NICU (Phase 1) and 5 at home (Phase 2). Parents provided daily opportunities designed to support the infants emerging motor control and exploratory behaviors. Primary outcome measures were assessed at the end of the intervention, 1 and 3 months after the intervention ended. Reaching was assessed with the infant supported in an infant chair using four 30 s trials. The Early Problem Solving Indicator was used to evaluate the frequency of behaviors during standardized play based assessment. Effect sizes are including for secondary outcomes including the Test of Infant Motor Performance and Bayley Scales of Infant and Toddler Development. RESULTS No group differences were found in the duration of toy contact. There was a significant group effect on (F1,8 = 4.04, p = 0.08) early exploratory problem-solving behaviors with infants in the SPEEDI group demonstrating greater exploration with effect sizes of 1.3, 0.6, and 0.9 at the end of the intervention, 1 and 3 months post-intervention. CONCLUSIONS While further research is needed, this initial efficacy study showed promising results for the ability of SPEEDI to impact early problem solving behaviors at the end of intervention and at least 3 months after the intervention is over. While reaching did not show group differences, a ceiling effect may have contributed to this finding. This single blinded pilot RCT was registered prior to subject enrollment on 5/27/14 at ClinicalTrials.Gov with number NCT02153736.
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Affiliation(s)
- Stacey C. Dusing
- Department of Physical Therapy, Motor Development Lab, Virginia Commonwealth University, Office: 1200 E Broad St. B106, PO BOX 980224, Richmond, VA 23298 USA
| | - Tanya Tripathi
- Rehabilitation and Movement Sciences Program, Virginia Commonwealth University, Richmond, USA
| | - Emily C. Marcinowski
- Department of Physical Therapy, Motor Development Lab, Virginia Commonwealth University, Office: 1200 E Broad St. B106, PO BOX 980224, Richmond, VA 23298 USA
| | - Leroy R. Thacker
- Schools of Nursing and Medicine, Virginia Commonwealth University, Richmond, USA
| | - Lisa F. Brown
- School of Nursing, Virginia Commonwealth University, Richmond, USA
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Pappas A, Adams-Chapman I, Shankaran S, McDonald SA, Stoll BJ, Laptook AR, Carlo WA, Van Meurs KP, Hintz SR, Carlson MD, Brumbaugh JE, Walsh MC, Wyckoff MH, Das A, Higgins RD. Neurodevelopmental and Behavioral Outcomes in Extremely Premature Neonates With Ventriculomegaly in the Absence of Periventricular-Intraventricular Hemorrhage. JAMA Pediatr 2018; 172:32-42. [PMID: 29181530 PMCID: PMC5833521 DOI: 10.1001/jamapediatrics.2017.3545] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
IMPORTANCE Studies of cranial ultrasonography and early childhood outcomes among cohorts of extremely preterm neonates have linked periventricular-intraventricular hemorrhage and cystic periventricular leukomalacia with adverse neurodevelopmental outcomes. However, the association between nonhemorrhagic ventriculomegaly and neurodevelopmental and behavioral outcomes is not fully understood. OBJECTIVE To characterize the outcomes of extremely preterm neonates younger than 27 weeks' gestational age who experienced nonhemorrhagic ventriculomegaly that was detected prior to 36 weeks' postmenstrual age. DESIGN, SETTING, AND PARTICIPANTS This longitudinal observational study was conducted at 16 centers of the Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network. Infants born prior to 27 weeks' gestational age in any network facility between July 1, 2006, and June 30, 2011, were included if they had a cranial ultrasonogram performed prior to 36 weeks' postmenstrual age. Comparisons were made between those with ventriculomegaly and those with normal cranial sonograms. Data analysis was completed from August 2013 to August 2017. MAIN OUTCOMES AND MEASURES The main outcome was neurodevelopmental impairment, defined as a Bayley Scales of Infant and Toddler Development III cognitive score less than 70, moderate/severe cerebral palsy, a Gross Motor Function Classification System score of level 2 or more, vision impairment, or hearing impairment. Secondary outcomes included Bayley Scales of Infant and Toddler Development III subscores, components of neurodevelopmental impairment, behavioral outcomes, and death/neurodevelopmental impairment. Logistic regression was used to evaluate the association of ventriculomegaly with adverse outcomes while controlling for potentially confounding variables and center differences as a random effect. Linear regression was used similarly for continuous outcomes. RESULTS Of 4193 neonates with ultrasonography data, 300 had nonhemorrhagic ventriculomegaly (7%); 3045 had normal cranial ultrasonograms (73%), 775 had periventricular-intraventricular hemorrhage (18.5%), and 73 had cystic periventricular leukomalacia (1.7%). Outcomes were available for 3008 of 3345 neonates with ventriculomegaly or normal scans (90%). Compared with normal cranial ultrasonograms, ventriculomegaly was associated with lower gestational age, male sex, and bronchopulmonary dysplasia, late-onset sepsis, meningitis, necrotizing enterocolitis, and stage 3 retinopathy of prematurity. After adjustment, neonates with ventriculomegaly had higher odds of neurodevelopmental impairment (odds ratio [OR], 3.07; 95% CI, 2.13-4.43), cognitive impairment (OR, 3.23; 95% CI, 2.09-4.99), moderate/severe cerebral palsy (OR, 3.68; 95% CI, 2.08-6.51), death/neurodevelopmental impairment (OR, 2.17; 95% CI, 1.62-2.91), but not death alone (OR, 1.09; 95% CI, 0.76-1.57). Behavioral outcomes did not differ. CONCLUSIONS AND RELEVANCE Nonhemorrhagic ventriculomegaly is associated with increased odds of neurodevelopmental impairment among extremely preterm neonates.
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Affiliation(s)
- Athina Pappas
- Department of Pediatrics, Wayne State University, Detroit, Michigan
| | - Ira Adams-Chapman
- Emory University School of Medicine, Department of Pediatrics, Children’s Healthcare of Atlanta, Atlanta, Georgia
| | - Seetha Shankaran
- Department of Pediatrics, Wayne State University, Detroit, Michigan
| | - Scott A. McDonald
- Social, Statistical and Environmental Sciences Unit, RTI International, Research Triangle Park, North Carolina
| | - Barbara J. Stoll
- Department of Pediatrics, McGovern Medical School at The University of Texas Health Science Center, Houston
| | - Abbot R. Laptook
- Department of Pediatrics, Women and Infants Hospital, Brown University, Providence, Rhode Island
| | | | - Krisa P. Van Meurs
- Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford University School of Medicine and Lucile Packard Children's Hospital, Palo Alto, California
| | - Susan R. Hintz
- Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford University School of Medicine and Lucile Packard Children's Hospital, Palo Alto, California
| | | | - Jane E. Brumbaugh
- Department of Pediatrics, University of Iowa, Iowa City,Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota
| | - Michele C. Walsh
- Department of Pediatrics, Rainbow Babies and Children’s Hospital, Case Western Reserve University, Cleveland, Ohio
| | - Myra H. Wyckoff
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas
| | - Abhik Das
- Social, Statistical, and Environmental Sciences Unit, RTI International, Rockville, Maryland
| | - Rosemary D. Higgins
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland
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Yanni D, Korzeniewski SJ, Allred EN, Fichorova RN, O'Shea TM, Kuban K, Dammann O, Leviton A. Both antenatal and postnatal inflammation contribute information about the risk of brain damage in extremely preterm newborns. Pediatr Res 2017; 82:691-696. [PMID: 28549057 PMCID: PMC5599336 DOI: 10.1038/pr.2017.128] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2016] [Accepted: 04/15/2017] [Indexed: 12/02/2022]
Abstract
BackgroundPreterm newborns exposed to intrauterine inflammation are at an increased risk of neurodevelopmental disorders. We hypothesized that adverse outcomes are more strongly associated with a combination of antenatal and postnatal inflammation than with either of them alone.MethodsWe defined antenatal inflammation as histologic inflammation in the placenta. We measured the concentrations of seven inflammation-related proteins in blood obtained on postnatal days 1, 7, and 14 from 763 infants born before 28 weeks of gestation. We defined postnatal inflammation as a protein concentration in the highest quartile on at least 2 days. We used logistic regression models to evaluate the contribution of antenatal and postnatal inflammation to the risk of neurodevelopmental disorders.ResultsThe risk of white matter damage was increased when placental inflammation was followed by sustained elevation of C-reactive protein or ICAM-1. We found the same for spastic cerebral palsy when placental inflammation was followed by elevation of TNF-α or IL-8. The presence of both placental inflammation and elevated levels of IL-6, TNF-α, or ICAM-1 was associated with an increased risk for microcephaly.ConclusionCompared with a single hit, two inflammatory hits are associated with stronger risk for abnormal cranial ultrasound, spastic cerebral palsy, and microcephaly at 2 years.
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Affiliation(s)
- Diana Yanni
- Division of Newborn Medicine, Department of Pediatrics, Floating Hospital for Children at Tufts Medical Center, Boston, Massachusetts
| | - Steven J. Korzeniewski
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, Michigan
| | - Elizabeth N. Allred
- Department of Neurology, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Raina N. Fichorova
- Departments of Obstetrics, Gynecology and Reproductive Biology, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - T. Michael O'Shea
- Department of Pediatrics, University of North Carolina, Chapel Hill North Carolina
| | - Karl Kuban
- Departments of Pediatrics and Neurology, Boston Medical Center and Boston University School of Medicine, Boston, Massachusetts
| | - Olaf Dammann
- Department of Public Health & Community Medicine, Tufts University School of Medicine, Boston, Massachusetts
| | - Alan Leviton
- Department of Neurology, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
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Park EJ, Kang J, Su H, Stegall P, Miranda DL, Hsu WH, Karabas M, Phipps N, Agrawal SK, Goldfield EC, Walsh CJ. Design and preliminary evaluation of a multi-robotic system with pelvic and hip assistance for pediatric gait rehabilitation. IEEE Int Conf Rehabil Robot 2017; 2017:332-339. [PMID: 28813841 DOI: 10.1109/icorr.2017.8009269] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
This paper presents a modular, computationally-distributed "multi-robot" cyberphysical system designed to assist children with developmental delays in learning to walk. The system consists of two modules, each assisting a different aspect of gait: a tethered cable pelvic module with up to 6 degrees of freedom (DOF), which can modulate the motion of the pelvis in three dimensions, and a two DOF wearable hip module assisting lower limb motion, specifically hip flexion. Both modules are designed to be lightweight and minimally restrictive to the user, and the modules can operate independently or in cooperation with each other, allowing flexible system configuration to provide highly customized and adaptable assistance. Motion tracking performance of approximately 2 mm root mean square (RMS) error for the pelvic module and less than 0.1 mm RMS error for the hip module was achieved. We demonstrate coordinated operation of the two modules on a mannequin test platform with articulated and instrumented lower limbs.
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Douglass LM, Heeren TC, Stafstrom CE, DeBassio W, Allred EN, Leviton A, O’Shea TM, Hirtz D, Rollins J, Kuban K. Cumulative Incidence of Seizures and Epilepsy in Ten-Year-Old Children Born Before 28 Weeks' Gestation. Pediatr Neurol 2017; 73:13-19. [PMID: 28619377 PMCID: PMC5524375 DOI: 10.1016/j.pediatrneurol.2017.05.009] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2017] [Revised: 05/01/2017] [Accepted: 05/11/2017] [Indexed: 11/29/2022]
Abstract
OBJECTIVE We evaluated the incidence of seizures and epilepsy in the first decade of life among children born extremely premature (less than 28 weeks' gestation). METHOD In a prospective, multicenter, observational study, 889 of 966 eligible children born in 2002 to 2004 were evaluated at two and ten years for neurological morbidity. Complementing questionnaire data to determine a history of seizures, all caregivers were interviewed retrospectively for postneonatal seizures using a validated seizure screen followed by a structured clinical interview by a pediatric epileptologist. A second pediatric epileptologist established an independent diagnosis based on recorded responses of the interview. A third epileptologist determined the final diagnosis when evaluators disagreed (3%). Life table survival methods were used to estimate seizure incidence through ten years. RESULTS By age ten years, 12.2% (95% confidence interval: 9.8, 14.5) of children had experienced one or more seizures, 7.6% (95% confidence interval: 5.7, 9.5) had epilepsy, 3.2% had seizure with fever, and 1.3% had a single, unprovoked seizure. The seizure incidence increased with decreasing gestational age. In more than 75% of children with seizures, onset was after one year of age. Seizure incidence was comparable in both sexes. Two-thirds of those with epilepsy had other neurological disorders. One third of children with epilepsy were not recorded on the medical history questionnaire. SIGNIFICANCE The incidence of epilepsy through age ten years among children born extremely premature is approximately 7- to 14-fold higher than the 0.5% to 1% lifetime incidence reported in the general pediatric population. Seizures in this population are under-recognized, and possibly underdiagnosed, by parents and providers.
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Affiliation(s)
- Laurie M. Douglass
- Department of Pediatrics and Neurology, Boston Medical Center, Boston, MA, USA
| | - Timothy C. Heeren
- Department of Biostatistics, Boston University School of Public Health, Boston, MA, USA
| | | | - William DeBassio
- Department of Pediatrics and Neurology, Boston Medical Center, Boston, MA, USA
| | - Elizabeth N. Allred
- Harvard Medical School, Boston, MA, USA,Boston Children’s Hospital, Boston, MA, USA
| | - Alan Leviton
- Harvard Medical School, Boston, MA, USA,Boston Children’s Hospital, Boston, MA, USA
| | - T. Michael O’Shea
- Department of Pediatrics, University of North Carolina, Chapel Hill, NC, USA
| | - Deborah Hirtz
- National Institute of Neurological Disorders and Stroke, Bethesda, MD, USA
| | - Julie Rollins
- Department of Pediatrics and Neurology, Boston Medical Center, Boston, MA, USA
| | - Karl Kuban
- Department of Pediatrics and Neurology, Boston Medical Center, Boston, MA, USA
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37
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Severe intraventricular hemorrhage and withdrawal of support in preterm infants. J Perinatol 2017; 37:441-447. [PMID: 27977011 DOI: 10.1038/jp.2016.233] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2016] [Revised: 10/29/2016] [Accepted: 11/07/2016] [Indexed: 01/26/2023]
Abstract
OBJECTIVE The objective of the study was to determine whether withdrawal of support in severe 'intraventricular hemorrhage' (IVH), that is, IVH grade 3 and periventricular hemorrhagic infarction (PVHI), has decreased after publication of studies that show improved prognosis and to examine cranial ultrasonograms, including PVHI territories defined by Bassan. STUDY DESIGN Retrospective cohort of preterm infants from 23 0/7 to 28 6/7 weeks' gestation in 1993 to 2013. RESULTS Among the 1755 infants, 1494 had no bleed, germinal matrix hemorrhage (GMH) or IVH grade 2, 137 had grade 3 IVH and 124 had PVHI. The odds of withdrawal of support, adjusted for severity of GMH-IVH and baseline variables, did not decrease after publications showing better prognosis. Among 82 patients who died with PVHI, 76 had life support withdrawn, including 34 without another contributing cause of death. The median number of PVHI territories involved was three. CONCLUSION Withdrawal of support adjusted for severity of GMH-IVH did not significantly change after publications showing better prognosis.
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Abstract
Infants born at extreme preterm gestation are at risk for both death and disability. Although rates of survival have improved for this population, and some evidence suggests a trend toward decreased neuromotor impairment over the past decades, a significant improvement in overall early neurodevelopmental outcome has not yet been realized. This review will examine the rates and types of neurodevelopmental impairment seen after extremely preterm birth, including neurosensory, motor, cognitive, and behavioral outcomes. We focus on early outcomes in the first 18-36 months of life, as the majority of large neonatal studies examining neurodevelopmental outcomes stop at this age. However, this early age is clearly just a first glimpse into lifetime outcomes; the neurodevelopmental effects of extreme prematurity may last through school age, adolescence, and beyond. Importantly, prematurity appears to be an independent risk factor for adverse development, but this population demonstrates considerable variability in the types and severity of impairments. Understanding both the nature and prevalence of neurodevelopmental impairment among extremely preterm infants is important because it can lead to targeted interventions that in turn may lead to improved outcomes.
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Affiliation(s)
- Elizabeth E Rogers
- Department of Pediatrics, UCSF Benioff Children's Hospital, University of California San Francisco, 550 4th St, 5th Floor, Box 0743, San Francisco, CA 94143.
| | - Susan R Hintz
- Division of Neonatal and Developmental Medicine, Stanford University School of Medicine, Lucile Packard Children's Hospital Stanford, Palo Alto, CA
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Abstract
There have been amazing changes in outcomes of preterm (PT) infants in the past decades. Whereas early studies reported only survival rates, Dr. Julius Hess published the first outcome study of PT infants in Chicago in 1953. Dr. Lubchenco then published the 10-year follow-up of premature infants born in 1947-1953 and identified a 68% handicap rate. As a result of these early studies, the importance of evaluating NICU graduates both for surveillance and as an outcome of trials was recognized. During the 1970s, there was a gradual expansion in the number of follow-up programs in the United States (US) with an increasing number of follow-up studies published. In the 1980s, the importance of multicenter clinical research networks was recognized and the NICHD Neonatal Research Network (NRN) was initiated in 1986. Follow-up protocols, definitions, and outcomes have evolved over the last 30 years and will be reviewed with a focus on NICHD NRN studies.
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Affiliation(s)
- Susan R Hintz
- Division of Neonatal and Developmental Medicine, Stanford University School of Medicine, 750 Welch Rd, Suite 315, Palo Alto, CA 94304
| | - Jamie E Newman
- Public Health Research Division, RTI International, Research Triangle Park, NC
| | - Betty R Vohr
- Alpert Medical School of Brown University, Providence, RI; Department of Pediatrics Women & Infants Hospital of Rhode Island, Providence, RI.
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40
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Nagaraj N, Berwal PK, Srinivas A, Sehra R, Swami S, Jeevaji P, Swami G, Choudary L, Berwal A. A study of neurosonogram abnormalities, clinical correlation with neurosonogram findings, and immediate outcome of high-risk neonates in Neonatal Intensive Care Unit. J Pediatr Neurosci 2016; 11:200-205. [PMID: 27857787 PMCID: PMC5108121 DOI: 10.4103/1817-1745.193367] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Neonatal sonography of the brain is now an essential part of newborn care, particularly in high risk and unstable premature infants. Cranial ultrasound is the most available and easily repeatable imaging technique for the neonatal brain showing brain development and the most frequently occurring forms of cerebral injury in the preterm and terms. This study aims to assess the importance of cranial ultrasound as an investigatory modality for high-risk neonates and to find out the morphology of various cerebral lesions and correlate clinically. METHODOLOGY An observational correlation clinical study was conducted at Sardar Patel Medical College, Bikaner involving 100 high-risk neonates admitted to Neonatal Intensive Care Unit (NICU) who was subjected to neurosonography on selected days as per protocol. Perinatal details were recorded, and clinical examination with appropriate investigations was done. The cranial ultrasound was done, and morphology of various findings was studied and recorded. Clinical correlation with cranial ultrasound findings and follow-up was done. RESULTS On cranial ultrasound, 38% of neonates had abnormal findings. Twelve percent of these had evidence of intracranial bleed, 13% periventricular echogenicity, 7% had ventriculomegaly, 2% had cerebral edema, and 1% had leukomalacia. Three neonates had findings suggestive of simple cyst in middle cranial fossa, agenesis of corpus callosum, and choroid plexus cyst. CONCLUSIONS Cranial ultrasonography is the best point of care neuroimaging method available for high-risk neonates. It is critical as an investigatory modality in NICU and effectively documents morphology of cerebral damage.
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Affiliation(s)
- Niranjan Nagaraj
- Department of Paediatrics, Sardar Patel Medical College, Bikaner, Rajasthan, India
| | - Pramod Kumar Berwal
- Department of Paediatrics, Sardar Patel Medical College, Bikaner, Rajasthan, India
| | - Anusha Srinivas
- Department of Paediatrics, Navodaya Medical College, Raichur, Karnataka, India
| | - Ramnarayan Sehra
- Department of Paediatrics, Sardar Patel Medical College, Bikaner, Rajasthan, India
| | - Sarika Swami
- Department of Paediatrics, Sardar Patel Medical College, Bikaner, Rajasthan, India
| | - Prathyusha Jeevaji
- Department of Paediatrics, Sardar Patel Medical College, Bikaner, Rajasthan, India
| | - Gotam Swami
- Department of Paediatrics, Sardar Patel Medical College, Bikaner, Rajasthan, India
| | - Lokesh Choudary
- Department of Paediatrics, Sardar Patel Medical College, Bikaner, Rajasthan, India
| | - Ayush Berwal
- Department of Paediatrics, Sardar Patel Medical College, Bikaner, Rajasthan, India
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Linsell L, Malouf R, Morris J, Kurinczuk JJ, Marlow N. Prognostic factors for cerebral palsy and motor impairment in children born very preterm or very low birthweight: a systematic review. Dev Med Child Neurol 2016; 58:554-69. [PMID: 26862030 PMCID: PMC5321605 DOI: 10.1111/dmcn.12972] [Citation(s) in RCA: 87] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/05/2015] [Indexed: 12/20/2022]
Abstract
AIM There is a large literature reporting risk factor analyses for poor neurodevelopment in children born very preterm (VPT: ≤32wks) or very low birthweight (VLBW: ≤1250g), which to date has not been formally summarized. The aim of this paper was to identify prognostic factors for cerebral palsy (CP) and motor impairment in children born VPT/VLBW. METHOD A systematic review was conducted using Medline, Embase, and Pyscinfo databases to identify studies published between 1 January 1990 and 1 June 2014 reporting multivariable prediction models for poor neurodevelopment in VPT/VLBW children (registration number CRD42014006943). Twenty-eight studies for motor outcomes were identified. RESULTS There was strong evidence that intraventricular haemorrhage and periventricular leukomalacia, and some evidence that the use of postnatal steroids and non-use of antenatal steroids, were prognostic factors for CP. Male sex and gestational age were of limited use as prognostic factors for CP in cohorts restricted to ≤32 weeks gestation; however, in children older than 5 years with no major disability, there was evidence that male sex was a predictive factor for motor impairment. INTERPRETATION This review has identified factors which may be of prognostic value for CP and motor impairment in VPT/VLBW children and will help to form the basis of future prognostic research.
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Affiliation(s)
- Louise Linsell
- National Perinatal Epidemiology Unit (NPEU), Nuffield Department of Population Health, University of Oxford, Headington, Oxford
| | - Reem Malouf
- National Perinatal Epidemiology Unit (NPEU), Nuffield Department of Population Health, University of Oxford, Headington, Oxford
| | - Joan Morris
- Queen Mary University of London, Centre for Environmental and Preventive Medicine, Barts and The London School of Medicine and Dentistry, London
| | - Jennifer J Kurinczuk
- National Perinatal Epidemiology Unit (NPEU), Nuffield Department of Population Health, University of Oxford, Headington, Oxford
| | - Neil Marlow
- Institute of Women’s Health, University College London, London, UK
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Hielkema T, Hadders-Algra M. Motor and cognitive outcome after specific early lesions of the brain - a systematic review. Dev Med Child Neurol 2016; 58 Suppl 4:46-52. [PMID: 27027607 DOI: 10.1111/dmcn.13047] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/01/2015] [Indexed: 11/30/2022]
Abstract
The aim of this systematic review was to study motor and cognitive outcome in infants with severe early brain lesions and to evaluate effects of side of the lesion, sex, and social economic status on outcome. A literature search was performed using the databases Pubmed and Embase. Included studies involved infants with either cystic periventricular leukomalacia (cPVL), preterm, or term stroke (i.e. parenchymal lesion of the brain). Outcome was expressed as cerebral palsy (CP) and intellectual disability (mental retardation). Median prevalence rates of CP after cPVL, preterm, and term stroke were 86%, 71%, and 29% respectively; of intellectual disability 50%, 27%, and 33%. Most infants with cPVL developed bilateral CP, those with term stroke unilateral CP, whereas after preterm stroke bilateral and unilateral CP occurred equally often. Information on the effects of sex and social economic status on outcome after specific brain lesions was very limited. Our findings show that the risk for CP is high after cPVL, moderate after preterm stroke, and lowest after term stroke. The risk for intellectual disability after an early brain lesion is lower than that for CP. Predicting outcome at individual level remains difficult; new imaging techniques may improve predicting developmental trajectories.
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Affiliation(s)
- Tjitske Hielkema
- University of Groningen, University Medical Center Groningen, Department of Paediatrics, Division of Developmental Neurology, Groningen, the Netherlands.,University of Groningen, University Medical Center Groningen, Center for Rehabilitation, Groningen, the Netherlands
| | - Mijna Hadders-Algra
- University of Groningen, University Medical Center Groningen, Department of Paediatrics, Division of Developmental Neurology, Groningen, the Netherlands
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Abstract
Cerebral palsy is the most common cause of childhood-onset, lifelong physical disability in most countries, affecting about 1 in 500 neonates with an estimated prevalence of 17 million people worldwide. Cerebral palsy is not a disease entity in the traditional sense but a clinical description of children who share features of a non-progressive brain injury or lesion acquired during the antenatal, perinatal or early postnatal period. The clinical manifestations of cerebral palsy vary greatly in the type of movement disorder, the degree of functional ability and limitation and the affected parts of the body. There is currently no cure, but progress is being made in both the prevention and the amelioration of the brain injury. For example, administration of magnesium sulfate during premature labour and cooling of high-risk infants can reduce the rate and severity of cerebral palsy. Although the disorder affects individuals throughout their lifetime, most cerebral palsy research efforts and management strategies currently focus on the needs of children. Clinical management of children with cerebral palsy is directed towards maximizing function and participation in activities and minimizing the effects of the factors that can make the condition worse, such as epilepsy, feeding challenges, hip dislocation and scoliosis. These management strategies include enhancing neurological function during early development; managing medical co-morbidities, weakness and hypertonia; using rehabilitation technologies to enhance motor function; and preventing secondary musculoskeletal problems. Meeting the needs of people with cerebral palsy in resource-poor settings is particularly challenging.
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van der Burg JW, Sen S, Chomitz VR, Seidell JC, Leviton A, Dammann O. The role of systemic inflammation linking maternal BMI to neurodevelopment in children. Pediatr Res 2016; 79:3-12. [PMID: 26375474 PMCID: PMC4888781 DOI: 10.1038/pr.2015.179] [Citation(s) in RCA: 92] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2015] [Accepted: 07/01/2015] [Indexed: 11/09/2022]
Abstract
Children of obese mothers are at increased risk of developmental adversities. Maternal obesity is linked to an inflammatory in utero environment, which, in turn, is associated with neurodevelopmental impairments in the offspring. This is an integrated mechanism review of animal and human literature related to the hypothesis that maternal obesity causes maternal and fetal inflammation, and that this inflammation adversely affects the neurodevelopment of children. We propose integrative models in which several aspects of inflammation are considered along the causative pathway linking maternal obesity with neurodevelopmental limitations.
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Affiliation(s)
- Jelske W. van der Burg
- Department of Health and Life Sciences, Faculty of Earth and Life Sciences, VU University Amsterdam, Amsterdam, The Netherlands
- Department of Public Health and Community Medicine, Tufts University School of Medicine, Boston, Massachusetts, USA
| | - Sarbattama Sen
- Department of Pediatrics and Mother Infant Research Institute, Floating Hospital for Children at Tufts Medical Center, Boston, Massachusetts, USA
- Jean Mayer Human Nutrition Research Center on Aging, Tufts University, Boston, Massachusetts, USA
| | - Virginia R. Chomitz
- Department of Public Health and Community Medicine, Tufts University School of Medicine, Boston, Massachusetts, USA
| | - Jaap C. Seidell
- Department of Health and Life Sciences, Faculty of Earth and Life Sciences, VU University Amsterdam, Amsterdam, The Netherlands
| | - Alan Leviton
- Department of Neurology, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Olaf Dammann
- Department of Public Health and Community Medicine, Tufts University School of Medicine, Boston, Massachusetts, USA
- Department of Neurology, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts, USA
- Perinatal Epidemiology Unit, Hannover Medical School, Hannover, Germany
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45
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Abstract
Preterm newborns are highly susceptible to brain injury. White matter injury is among the dominant patterns of brain injury in preterm newborns. the purpose of this review is to discuss the pathogenesis, diagnosis, management, and prevention of white matter injury in premature newborns. the long-term outcome of white matter injury in children born prematurely is also addressed.
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Affiliation(s)
- Dawn Gano
- UCSF Benioff Children's Hospital, 550 16th Street, Box 0137, San Francisco, CA 94158, USA
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46
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O'Dell MC, Cassady C, Logsdon G, Varich L. Cinegraphic versus Combined Static and Cinegraphic Imaging for Initial Cranial Ultrasound Screening in Premature Infants. Pediatr Radiol 2015; 45:1706-11. [PMID: 26008871 DOI: 10.1007/s00247-015-3382-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2014] [Revised: 03/07/2015] [Accepted: 05/06/2015] [Indexed: 11/28/2022]
Abstract
BACKGROUND Cranial ultrasound is an essential screening and diagnostic tool in the care of neonates and is especially useful in the premature population for evaluation of potential germinal matrix/intraventricular hemorrhage (GM/IVH). There are typically two screening examinations, with the initial cranial sonography performed between 3 days and 14 days after birth, usually consisting of a series of static images plus several cinegraphic sweeps. OBJECTIVE Our primary goal was to assess whether cinegraphic sweeps alone are as accurate for diagnosing neurological abnormalities as combined static and cinegraphic imaging in the initial cranial US evaluation of premature infants. Our secondary goal was to establish the difference in time required to perform these two examinations. MATERIALS AND METHODS We retrospectively obtained 140 consecutive initial cranial US screening studies of premature infants. Three pediatric radiologists blinded to patient data read cinegraphic images alone and also combined (dual) imaging sets for a subset of subjects, recording findings for seven disease processes: germinal matrix/intraventricular hemorrhage (GM/IVH), right or left side; periventricular leukomalacia (PVL); choroid plexus cyst; subependymal cyst; cerebral and cerebellar infarction or hemorrhage; posterior fossa hemorrhage or infarction, and extra-axial hemorrhage. Separately, we compared retrospective dual imaging acquisition time against prospectively collected cinegraphic imaging time for premature infants undergoing initial cranial US evaluation. RESULTS Equivalence testing demonstrated no difference in equivalency between initial cranial US screening using cinegraphic evaluation alone and dual imaging for GM/IVH, cerebral and cerebellar infarct or hemorrhage, and subependymal cyst (all P < 0.05). For PVL and choroid plexus cyst, cinegraphic imaging and dual imaging did not demonstrate equivalence (P > 0.05). Cinegraphic images were obtained in less than one-third of the time required for dual imaging. CONCLUSION For the diagnoses that are critical to establish at initial screening (GM/IVH, cerebral and cerebellar infarct or hemorrhage) initial cranial US screening using cinegraphic sweeps was equivalent to dual imaging. Cinegraphic imaging required significantly less time to perform than dual imaging. We suggest that performance of cranial US screening using cinegraphic imaging alone is a potentially advantageous option in the initial evaluation of the premature neonate.
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Affiliation(s)
- M Cody O'Dell
- Department of Diagnostic Radiology, Florida Hospital, 601 E. Rollins St., Orlando, FL, 32803, USA.
| | - Christopher Cassady
- Department of Diagnostic Radiology, Texas Children's Hospital, Houston, TX, USA
| | - Gregory Logsdon
- Department of Diagnostic Radiology, Florida Hospital, 601 E. Rollins St., Orlando, FL, 32803, USA
| | - Laura Varich
- Department of Diagnostic Radiology, Florida Hospital, 601 E. Rollins St., Orlando, FL, 32803, USA
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47
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Hirtz DG, Weiner SJ, Bulas D, DiPietro M, Seibert J, Rouse DJ, Mercer BM, Varner MW, Reddy UM, Iams JD, Wapner RJ, Sorokin Y, Thorp JM, Ramin SM, Malone FD, Carpenter MW, O'Sullivan MJ, Peaceman AM, Hankins GDV, Dudley D, Caritis SN. Antenatal Magnesium and Cerebral Palsy in Preterm Infants. J Pediatr 2015; 167:834-839.e3. [PMID: 26254839 PMCID: PMC4587284 DOI: 10.1016/j.jpeds.2015.06.067] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2014] [Revised: 05/14/2015] [Accepted: 06/29/2015] [Indexed: 10/23/2022]
Abstract
OBJECTIVE To evaluate the relationship of maternal antenatal magnesium sulfate (MgSO4) with neonatal cranial ultrasound abnormalities and cerebral palsy (CP). STUDY DESIGN In a randomized trial of MgSO4 or placebo in women at high risk of preterm delivery, up to 3 cranial ultrasounds were obtained in the neonatal period. Images were reviewed by at least 2 pediatric radiologists masked to treatment and other clinical conditions. Diagnoses were predefined for intraventricular hemorrhage, periventricular leukomalacia, intracerebral echolucency or echodensity, and ventriculomegaly. CP was diagnosed at 2 years of age by standardized neurologic examination. RESULTS Intraventricular hemorrhage, periventricular leukomalacia, intracerebral echolucency or echodensity, and ventriculomegaly were all strongly associated with an increased risk of CP. MgSO4 administration did not affect the risk of cranial ultrasound abnormality observed at 35 weeks postmenstrual age or later. However, for the 82% of infants born at <32 weeks gestation, MgSO4 was associated with a reduction in risk of echolucency or echodensity. The reduction in risk for echolucency explained 21% of the effect of MgSO4 on CP (P = .04), and for echodensity explained 20% of the effect (P = .02). CONCLUSIONS MgSO4 given prior to preterm delivery was associated with decreased risk of developing echodensities and echolucencies at <32 weeks gestation. However, this effect can only partially explain the effect of MgSO4 on CP at 2 years of age. TRIAL REGISTRATION ClinicalTrials.gov: NCT00014989.
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Affiliation(s)
- Deborah G Hirtz
- National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD
| | - Steven J Weiner
- Biostatistics Center, The George Washington University, Washington, DC
| | - Dorothy Bulas
- Department of Diagnostic Imaging and Radiology, Children's National Medical Center, Washington, DC
| | - Michael DiPietro
- Section of Pediatric Radiology, University of Michigan, Ann Arbor, MI
| | - Joanna Seibert
- Division of Radiology, Arkansas Children's Hospital, Little Rock, AR
| | - Dwight J Rouse
- Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, AL
| | - Brian M Mercer
- Department of Obstetrics and Gynecology, Case Western Reserve University-MetroHealth Medical Center, Cleveland, OH, and University of Tennessee, Memphis, TN
| | - Michael W Varner
- Department of Obstetrics and Gynecology, University of Utah Health Sciences Center, Salt Lake City, UT
| | - Uma M Reddy
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD
| | - Jay D Iams
- Department of Obstetrics and Gynecology, The Ohio State University, Columbus, OH
| | - Ronald J Wapner
- Department of Obstetrics and Gynecology, Thomas Jefferson University and Drexel University, Philadelphia, PA
| | - Yoram Sorokin
- Department of Obstetrics and Gynecology, Wayne State University, Detroit, MI
| | - John M Thorp
- Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Susan M Ramin
- Department of Obstetrics and Gynecology, University of Texas Health Science Center at Houston-Children's Memorial Hermann Hospital, Houston, TX
| | - Fergal D Malone
- Department of Obstetrics and Gynecology, Columbia University, New York, NY
| | | | - Mary J O'Sullivan
- Department of Obstetrics and Gynecology, University of Miami, Miami, FL
| | - Alan M Peaceman
- Department of Obstetrics and Gynecology, Northwestern University, Chicago, IL
| | - Gary D V Hankins
- Department of Obstetrics and Gynecology, University of Texas Medical Branch, Galveston, TX
| | - Donald Dudley
- Department of Obstetrics and Gynecology, University of Texas at San Antonio, San Antonio, TX
| | - Steve N Caritis
- Department of Obstetrics and Gynecology, University of Pittsburgh, Pittsburgh, PA
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Early prediction of the neurological result at 12 months in newborns at neurological risk. ANALES DE PEDIATRÍA (ENGLISH EDITION) 2015. [DOI: 10.1016/j.anpede.2015.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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Andrew MJ, Parr JR, Montague-Johnson C, Braddick O, Laler K, Williams N, Baker B, Sullivan PB. Optimising nutrition to improve growth and reduce neurodisabilities in neonates at risk of neurological impairment, and children with suspected or confirmed cerebral palsy. BMC Pediatr 2015; 15:22. [PMID: 25885548 PMCID: PMC4389808 DOI: 10.1186/s12887-015-0339-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2014] [Accepted: 02/26/2015] [Indexed: 12/02/2022] Open
Abstract
Background Neurological impairment is a common sequelae of perinatal brain injury. Plasticity of the developing brain is due to a rich substrate of developing neurones, synaptic elements and extracellular matrix. Interventions supporting this inherent capacity for plasticity may improve the developmental outcome of infants following brain injury. Nutritional supplementation with combination docosahexaenoic acid, uridine and choline has been shown to increase synaptic elements, dendritic density and neurotransmitter release in rodents, improving performance on cognitive tests. It remains elusive whether such specific ‘neurotrophic’ supplementation enhances brain plasticity and repair after perinatal brain injury. Methods/Design This is a two year double-blind, randomised placebo controlled study with two cohorts to investigate whether nutritional intervention with a neurotrophic dietary supplement improves growth and neurodevelopmental outcomes in neonates at significant risk of neurological impairment (the D1 cohort), and infants with suspected or confirmed cerebral palsy (the D2 cohort). 120 children will be randomised to receive dietetic and nutritional intervention, and either active supplement or placebo. Eligible D1 neonates are those born <30+6 weeks gestation with weight <9th centile, ≤30+6 weeks gestation and Grade II, III or IV Intra-Ventricular Haemorrhage or periventricular white matter injury, or those born at 31-40+28 weeks gestation, with Sarnat grade I or II or III Hypoxic Ischaemic Encephalopathy or neuroimaging changes compatible with perinatal brain injury. Eligible D2 infants are those aged 1-18 months with a suspected or confirmed clinical diagnosis of cerebral palsy. The primary outcome measure is composite cognitive score on the Bayley Scales of Infant and Toddler Development III at 24 months. Secondary outcomes include visuobehavioural and visual neurophysiological assessments, and growth parameters including weight, height, and head circumference. Discussion This is the first study to supplement neonates and infants with perinatal brain injury with the combination of factors required for healthy brain development, throughout the period of maximal brain growth. A further study strength is the comprehensive range of outcome measures employed. If beneficial, supplementation with brain phosphatide precursors could improve the quality of life of thousands of children with perinatal brain injury. Trial registration Current Controlled trials: ISRCTN39264076 (registration assigned 09/11/2012), ISRCTN15239951 (registration assigned 23/04/2010).
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Affiliation(s)
- Morag J Andrew
- Department of Paediatrics, Oxford University, Level 2, Oxford Children's Hospital, Oxford, OX3 9DU, UK.
| | - Jeremy R Parr
- Institute of Neuroscience, Newcastle University, Sir James Spence Institute, Royal Victoria Infirmary, Newcastle Upon Tyne, NE1 4LP, UK.
| | - Chris Montague-Johnson
- Department of Paediatrics, Oxford University, Level 2, Oxford Children's Hospital, Oxford, OX3 9DU, UK.
| | - Oliver Braddick
- Department Experimental Psychology, University of Oxford, South Parks Road, Oxford, OX1 3UD, UK.
| | - Karen Laler
- Department of Paediatrics, Oxford University, Level 2, Oxford Children's Hospital, Oxford, OX3 9DU, UK.
| | - Nicola Williams
- Centre for Statistics in Medicine, University of Oxford, Botnar Research centre, Windmill Road, Oxford, OX3 7LD, UK.
| | - Bonny Baker
- Department of Paediatrics, Oxford University, Level 2, Oxford Children's Hospital, Oxford, OX3 9DU, UK.
| | - Peter B Sullivan
- Department of Paediatrics, Oxford University, Level 2, Oxford Children's Hospital, Oxford, OX3 9DU, UK.
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50
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Hintz SR, Barnes PD, Bulas D, Slovis TL, Finer NN, Wrage LA, Das A, Tyson JE, Stevenson DK, Carlo WA, Walsh MC, Laptook AR, Yoder BA, Van Meurs KP, Faix RG, Rich W, Newman NS, Cheng H, Heyne RJ, Vohr BR, Acarregui MJ, Vaucher YE, Pappas A, Peralta-Carcelen M, Wilson-Costello DE, Evans PW, Goldstein RF, Myers GJ, Poindexter BB, McGowan EC, Adams-Chapman I, Fuller J, Higgins RD. Neuroimaging and neurodevelopmental outcome in extremely preterm infants. Pediatrics 2015; 135:e32-42. [PMID: 25554820 PMCID: PMC4279063 DOI: 10.1542/peds.2014-0898] [Citation(s) in RCA: 189] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Extremely preterm infants are at risk for neurodevelopmental impairment (NDI). Early cranial ultrasound (CUS) is usual practice, but near-term brain MRI has been reported to better predict outcomes. We prospectively evaluated MRI white matter abnormality (WMA) and cerebellar lesions, and serial CUS adverse findings as predictors of outcomes at 18 to 22 months' corrected age. METHODS Early and late CUS, and brain MRI were read by masked central readers, in a large cohort (n = 480) of infants <28 weeks' gestation surviving to near term in the Neonatal Research Network. Outcomes included NDI or death after neuroimaging, and significant gross motor impairment or death, with NDI defined as cognitive composite score <70, significant gross motor impairment, and severe hearing or visual impairment. Multivariable models evaluated the relative predictive value of neuroimaging while controlling for other factors. RESULTS Of 480 infants, 15 died and 20 were lost. Increasing severity of WMA and significant cerebellar lesions on MRI were associated with adverse outcomes. Cerebellar lesions were rarely identified by CUS. In full multivariable models, both late CUS and MRI, but not early CUS, remained independently associated with NDI or death (MRI cerebellar lesions: odds ratio, 3.0 [95% confidence interval: 1.3-6.8]; late CUS: odds ratio, 9.8 [95% confidence interval: 2.8-35]), and significant gross motor impairment or death. In models that did not include late CUS, MRI moderate-severe WMA was independently associated with adverse outcomes. CONCLUSIONS Both late CUS and near-term MRI abnormalities were associated with outcomes, independent of early CUS and other factors, underscoring the relative prognostic value of near-term neuroimaging.
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Affiliation(s)
- Susan R. Hintz
- Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford University School of Medicine and Lucile Packard Children’s Hospital, Palo Alto, California
| | - Patrick D. Barnes
- Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford University School of Medicine and Lucile Packard Children’s Hospital, Palo Alto, California
| | - Dorothy Bulas
- Department of Diagnostic Imaging and Radiology, Children’s National Medical Center, Washington, District of Columbia
| | - Thomas L. Slovis
- Department of Pediatric Imaging, Children’s Hospital of Michigan, Wayne State School of Medicine, Detroit, Michigan
| | | | - Lisa A. Wrage
- Social, Statistical, and Environmental Sciences Unit, RTI International, Research Triangle Park, North Carolina
| | - Abhik Das
- Social, Statistical, and Environmental Sciences Unit, RTI International, Rockville, Maryland
| | - Jon E. Tyson
- Department of Pediatrics, University of Texas Medical School–Houston, Houston, Texas
| | - David K. Stevenson
- Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford University School of Medicine and Lucile Packard Children’s Hospital, Palo Alto, California
| | - Waldemar A. Carlo
- Division of Neonatology, University of Alabama–Birmingham, Birmingham, Alabama
| | - Michele C. Walsh
- Department of Pediatrics, Rainbow Babies & Children’s Hospital, Case Western Reserve University, Cleveland, Ohio
| | - Abbot R. Laptook
- Department of Pediatrics, Women & Infants Hospital, Brown University, Providence, Rhode Island
| | - Bradley A. Yoder
- Division of Neonatology, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah
| | - Krisa P. Van Meurs
- Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford University School of Medicine and Lucile Packard Children’s Hospital, Palo Alto, California
| | - Roger G. Faix
- Division of Neonatology, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah
| | - Wade Rich
- Departments of Neonatology, and,Pediatrics, University of California–San Diego, San Diego, California
| | - Nancy S. Newman
- Department of Pediatrics, Rainbow Babies & Children’s Hospital, Case Western Reserve University, Cleveland, Ohio
| | - Helen Cheng
- Social, Statistical, and Environmental Sciences Unit, RTI International, Research Triangle Park, North Carolina
| | - Roy J. Heyne
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Betty R. Vohr
- Department of Pediatrics, Women & Infants Hospital, Brown University, Providence, Rhode Island
| | | | - Yvonne E. Vaucher
- Pediatrics, University of California–San Diego, San Diego, California
| | - Athina Pappas
- Department of Pediatrics, Wayne State University, Detroit, Michigan
| | | | - Deanne E. Wilson-Costello
- Department of Pediatrics, Rainbow Babies & Children’s Hospital, Case Western Reserve University, Cleveland, Ohio
| | - Patricia W. Evans
- Department of Pediatrics, University of Texas Medical School–Houston, Houston, Texas
| | | | - Gary J. Myers
- Department of Pediatrics, University of Rochester Medical Center, Rochester, New York
| | - Brenda B. Poindexter
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, Indiana
| | - Elisabeth C. McGowan
- Division of Newborn Medicine, Department of Pediatrics, Floating Hospital for Children, Tufts Medical Center, Boston, Massachusetts
| | - Ira Adams-Chapman
- Department of Pediatrics, Emory University School of Medicine, and Children’s Healthcare of Atlanta, Atlanta, Georgia
| | - Janell Fuller
- University of New Mexico Health Sciences Center, Albuquerque, New Mexico; and
| | - Rosemary D. Higgins
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland
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