New Ballard Score, expanded to include extremely premature infants

Part 1: a matter of size: evaluating the growth-restricted neonate

The relative size of a neonate impacts many aspects of prenatal and postnatal surveillance and care. The designations of appropriate for gestational age, small-for-gestational age, intrauterine growth restriction, and large-for-gestational age are systematic categorizations used to assess and monitor growth throughout pregnancy and delivery. Each abnormal growth descriptor aids in anticipating neonatal needs after birth because each has the potential for complications related to feeding, glucose utilization, short- and long-term growth, and development. Maternal risk factors that impact the neonate's size-related can have immediate implications in the delivery room as well as significant effects postnatally. Caring for neonates at risk for size complications requires knowledge based on prenatal and postnatal complications. Neonates must be carefully measured and plotted on growth charts to confirm a visual assessment of size. Each growth complication requires individual attention to detail and careful planning to maximize adequate postnatal growth and nutrition. Size matters when it comes to the health and welfare of neonates. Anticipatory guidance can improve outcomes in the neonate at risk for failure to thrive from size complications at birth. Part 1 of this article provides an overview of the size classifications and a discussion of clinical factors that are associated with or contribute to small-for-gestational age births. Once the neonate's size for gestational age is calculated, a focused physical assessment is described along with nursing care and prognostic implications. Part 2 will focus on the physical assessment, nursing care, prognosis, and complications associated with large-for-gestational-age neonates.

Exposure to marijuana during pregnancy alters neurobehavior in the early neonatal period

OBJECTIVE

To assess the neurobehavior of full-term neonates of adolescent mothers exposed to marijuana during pregnancy.

STUDY DESIGN

This prospective cross-sectional study included full-term infants within 24 to 72 hours of life born to adolescent mothers at a single center in Brazil. Data on sociodemographic and obstetrical and neonatal characteristics were collected. The mothers underwent the Composite International Diagnostic Interview, and the infants were assessed with the Neonatal Intensive Care Unit Network Neurobehavioral Scale (NNNS). Maternal hair and neonatal meconium were analyzed. Neonates exposed in utero to tobacco, alcohol, cocaine, and/or any other drugs except marijuana were excluded.

RESULTS

Of 3685 infants born in the study hospital, 928 (25%) were born to adolescent mothers. Of these, 561 infants met the inclusion criteria and were studied. Marijuana exposure was detected in 26 infants (4.6%). Infants exposed (E) or not exposed (NE) to marijuana differed in the following NNNS variables: arousal (E, 4.05 +/- 1.19 vs NE, 3.68 +/- 0.70), regulation (E, 5.75 +/- 0.62 vs NE, 6.04 +/- 0.72), and excitability (E, 3.27 +/- 1.40 vs NE, 2.40 +/- 1.57). After controlling for confounding variables, the effect of marijuana exposure on these scores remained significant.

CONCLUSIONS

Marijuana exposure during pregnancy alters the neurobehavioral performance of term newborn infants of adolescent mothers.

Response inhibition during Differential Reinforcement of Low Rates (DRL) schedules may be sensitive to low-level polychlorinated biphenyl, methylmercury, and lead exposure in children

BACKGROUND

Animal studies have shown that exposure to common, low-level environmental contaminants [e.g., polychlorinated biphenyls (PCBs), lead] causes excessive and inappropriate responding on intermittent reinforcement schedules. The Differential Reinforcement of Low Rates task (DRL) has been shown to be especially sensitive to low-level PCB exposure in monkeys.

OBJECTIVES

We investigated the relationships between prenatal PCB and postnatal Pb exposure performance on a DRL schedule in children. We predicted that a) prenatal PCB exposure would reduce interresponse times (IRTs) and reinforcements earned, and b) postnatal Pb exposure would reduce IRTs and reinforcements earned.

METHODS

We tested 167 children on a DRL20 (20 sec) reinforcement schedule, and recorded IRTs and the number of reinforced responses across the session. We measured prenatal PCB exposure (cord blood), methylmercury (MeHg) (maternal hair), and postnatal Pb exposure (venous blood), and > 50 potentially confounding variables.

RESULTS

Results indicated impaired performance in children exposed to PCBs, MeHg, and Pb. Children prenatally exposed to PCBs responded excessively, with significantly lower IRTs and fewer reinforcers earned across the session. In addition, exposure to either MeHg or Pb predicted statistically significant impairments of a similar magnitude to those for PCBs, and the associated impairments of all three contaminants (PCB, MeHg, and Pb) were statistically independent of one another.

CONCLUSIONS

These results, taken with animal literature, argue the high sensitivity of DRL performance to low-level PCB, MeHg, and Pb exposure. Future research should employ behavioral tasks in children, such as DRL, that have been demonstrably sensitive to low-level PCB, MeHg, and Pb exposure in animals.

Maternal antiretroviral drugs during pregnancy and infant low birth weight and preterm birth

OBJECTIVE

To determine the relationship between maternal antiretroviral regimens during pregnancy and adverse infant outcomes [low birth weight (LBW) and preterm birth]. The a priori hypothesis was that protease inhibitor (PI)-containing regimens are associated with an increased risk of LBW and preterm birth.

DESIGN

Prospective cohort study of HIV-1-infected women and their infants (NISDI Perinatal Study).

METHODS

Data were analysed from 681 women receiving at least one antiretroviral drug [in order of increasing complexity: one or two nucleoside reverse transcriptase inhibitors (1-2 NRTI), two NRTI plus one non-nucleoside reverse transcriptase inhibitor (NNRTI) (HAART/NNRTI), or two NRTI plus one PI (HAART/PI)] for at least 28 days during pregnancy, and who delivered live born, singleton infants with known birth weight and gestational age by 1 March 2005. Multivariable logistic regression modeling was used to assess the relationship of maternal ART with LBW and with preterm birth, adjusting for covariates.

RESULTS

The incidence of LBW and preterm birth, respectively, was 9.6% and 7.4% (1-2 NRTI), 7.4% and 5.8% (HAART/NNRTI), and 16.7% and 10.6% (HAART/PI). There was no statistically significant increased risk of LBW [adjusted odds ratio (AOR), 1.5; 95% confidence interval (95% CI), 0.7-3.2] or preterm birth (AOR, 1.1; 95% CI, 0.5-2.8) among women who received HAART/PI compared with women receiving 1-2 NRTI.

CONCLUSIONS

Among a population of HIV-1-infected women in Latin America and the Caribbean, maternal receipt of PI-containing ART regimens during pregnancy was not associated with a statistically significant increase in risk of LBW or preterm birth.

Influence of genetic polymorphisms on bone disease of preterm infants

Bone disease is an important complication among very low birth weight (VLBW, <1500 g) infants. In adults, osteoporosis is associated with polymorphisms of vitamin D receptor (VDR), estrogen receptor (ER), and collagen Ialpha1 (COLIA1) genes. However, limited information is available regarding the role of these polymorphisms in bone disease in premature infants. We have investigated the possible association between bone disease and the allelic polymorphisms of these three genes in 65 VLBW infants. Twenty infants (30.8%) were diagnosed with bone disease based on high activity of bone formation (serum alkaline phosphatase and osteocalcin), bone resorption (urinary excretion of calcium and pyridinium crosslink) markers, and positive radiologic signs. Statistically significant correlation between thymine-adenine repeat [(TA)(n)] allelic variant of ER gene and bone disease was observed. Infants without bone disorder more often carried a high number of repeats [(TA)(n) >18] [odds ratio (OR): 0.17, 95% confidence interval (CI): 0.05-0.55]. A low number of repeats [(TA)(n) <19] was found more frequently in infants suffering from bone disease (OR: 6.00, 95% CI: 1.77-20.31). Significant interaction (p = 0.009) between VDR and COLIA1 genotypes was observed. In a logistic regression model, bone disorder of preterms significantly correlated with male gender (p = 0.002), lower gestational age (p = 0.015), homozygous allelic variants of high number of (TA)(n) repeats (p = 0.006), and interaction between VDR and COLIA1 genotype (p = 0.009).

Persistent high activity of the fetal adrenal cortex in preterm infants: is there a clinical significance?

BACKGROUND

In preterm infants, the activity of the fetal adrenal cortex continues until term. Dehydroepiandrosterone sulphate can block the synthesis of surfactant in vitro. The incidence of pulmonary disease is higher in male than in female preterm infants.

OBJECTIVE

To investigate the relationship between urinary excretion of fetal zone steroids (3beta-OH-5-ene-steroids) and the severity of lung disease in preterm infants with respect to gender.

PATIENTS AND METHODS

3beta-OH-5-ene-steroids were profiled by gas chromatography-mass spectrometry in 24-h urinary samples in 61 preterm infants of less than 30 weeks gestational age.

RESULTS

The incidence of respiratory distress syndrome treated with surfactant in females (n = 30) was 47% and in males (n = 31) 71%, p = 0.07. Medians of total excretion rates of fetal zone steroids (microg/kg/d) in female (male) preterm infants were at day 1: 1,317 (895); day 2: 3,154 (7,723), p = 0.03; day 3: 5,502 (9,494), p = 0.08; day 5: 7,140 (10,407); week 2: 8,731 (9,720); week 3: 8,571 (10,079); week 4: 7,620 (7,825). Regression analysis did not reveal a significant influence of maximum excretion rates of fetal zone steroids or gender on the incidence of respiratory distress syndrome treated with surfactant.

CONCLUSIONS

Excretion rates of fetal zone steroids were 4-fold higher than previously reported indicating a persistent high activity of the fetal adrenal zone in preterm infants. Excretion rates of fetal zone steroids were significantly higher in male preterm infants compared to females at day 2 (trend at day 3) but did not have a significant influence on the incidence of respiratory distress syndrome.

Plasma KL-6 predicts the development and outcome of bronchopulmonary dysplasia

Circulating KL-6 is a specific indicator of pulmonary injury affecting the alveolar epithelium and interstitium. Our preliminary study suggested the usefulness of plasma KL-6 as a marker of bronchopulmonary dysplasia (BPD). To confirm the diagnostic value of KL-6 for BPD as well as to determine the reference range, we conducted a larger prospective study in 135 preterm infants <32 wk GA. Among the infants without oxygen dependence at a postconceptional age of 36 wk, the plasma KL-6 level showed no significant association with GA at any time. Among 42 infants <28 wk GA, plasma KL-6 levels were significantly higher in those with moderate/severe BPD compared with those with no/mild BPD. A plasma level of 199 U/mL at 1 wk or 232 U/mL at 2 wk was an excellent predictor of moderate/severe BPD <28 wk GA (positive predictive value of 83% and 80%, respectively). Unlike nonspecific markers of inflammation or fibrosis, KL-6 objectively reflects the severity of pulmonary injury irrespective of the treatment or the radiographic changes. Therefore, not only as a good marker, measurement of KL-6 may also help to provide new insights into the pathogenesis of BPD.

Newborn screening levels of 17-hydroxyprogesterone in very low birth weight infants and the relationship to chronic lung disease

OBJECTIVES

17-Hydroxyprogesterone (17-OHP), an intermediary hormone in cortisol synthesis, has been shown to be elevated in premature infants. However, the relationship between levels of 17-OHP with chronic lung disease (CLD) have not been extensively explored. The objective of this study was to determine whether there is an association between CLD and levels of 17-OHP in a population of very low birth weight infants.

STUDY DESIGN

Cohort study of very low birth weight infants cared for at a single level 3 NICU during a 3-year period from July 2001-July 2004, n=435. Infants had a minimum of one screen for 17-OHP. 17-OHP was measured on the 5th day of life and at 2-4 weeks of life as part of the State of Delaware Newborn Screening Program. Statistical analysis included chi-squared, Pearson correlation, and logistic regression.

RESULTS

Levels of 17-OHP were higher at the time of the 1st screen compared to the 2nd screen (42.2 +/- 36.7 vs 23.5 +/- 32.3 ng/ml, respectively, p = 0.01). After controlling for potential confounding variables, gestational age and prenatal steroids were independently associated with 17-OHP. However, logistic regression analysis showed no association between a 1 log increase in levels of 17-OHP with the outcomes of CLD (odds ratio 1.7, 95% CI 0.7-3.8), or death and/or CLD (odds ratio 2.1, 95% CI 0.9-4.8).

CONCLUSIONS

In our population of very low birth weight infants elevated levels of 17-OHP were not associated with the development of CLD.

Equations describing percentiles for birth weight, head circumference, and length of preterm infants

OBJECTIVE

To describe growth of prematurely born infants and create a growth chart adequate to assess growth of infants with less than 29 completed weeks of gestation.

STUDY DESIGN

Birth weight, head circumference and length measurements of 7,425 liveborn preterm infants from 1985 to 1997 were retrieved from a longitudinal database maintained by the neonatology division. The 3rd, 5th, 10th, 15th, 25th, 50th, 75th, 85th, 90th, 95th and 97th percentiles of each measurement were determined and used for mathematical modeling.

RESULTS

Birth weight was described with an exponential function while head circumference and length were described with linear functions. A preterm growth chart for the 10th, 50th and 90th percentiles for birth weight, weight growth, head circumference and length was generated.

CONCLUSION

The mathematical models of growth provide smooth representations of the percentiles across gestational ages.

Quantitative MRI measurements of human fetal brain development in utero

Magnetic resonance imaging (MRI) allows for high resolution imaging of the central nervous system. We have tested the feasibility of using MRI in conjunction with quantitative image analysis to perform volumetric measurements of the brain in the developing human fetus in utero. The database comprises MR images of a total of 56 fetuses (gestational age 25-41 weeks) referred because of suspected abnormalities due to ultrasound findings, family history or maternal illness and scanned on a 1.5 T MR system using a single-shot fast spin echo (SSFSE) T2 sequence, slice thickness 3 mm, no gap. Four out of the 56 scans could not be used in the analysis due to poor image quality. Automatic segmentation (using NIH Image routines) was found to be unreliable in these fetal brains, so cerebral, cerebellar and ventricular regions were traced manually. Ventricular volumes did not vary with gestational age in normal fetuses (N=27, R=0.05, p=0.8) while cerebral parenchyma and cerebellum volumes increased significantly during the same period (R=0.67, p=0.0002 and R=0.51, p=0.0066 respectively). Two calculated parameters: percent ventricular asymmetry and volume ratio of ventricles to hemispheric parenchyma were found to be very sensitive to ventricular pathology; such that the mean value of the latter in normal fetuses was 4.4%+/-0.56 (mean+/-SEM, N=27) compared to 34.3%+/-17.6 (N=6, p<0.0001) in fetuses with ventriculomegaly. These results support the use of image analysis and MRI to produce normal growth curves as well as quantitative severity assessments of brain pathologies in the developing human fetus.

Intrauterine Inflammation and the Onset of Peri-Intraventricular Hemorrhage in Premature Infants

BACKGROUND

Peri-intraventricular hemorrhage (P/IVH) is a common neonatal morbidity among premature infants. The aim of the study was to examine the association between placental and/or fetal inflammation and the onset of P/IVH in premature infants.

METHODS

A prospective study included 125 infants with gestational age 23-29 weeks. Placentas were examined for the presence of chorioamnionitis and funisitis, cord blood was sampled for the measurement of cytokines (IL-6 and IL-8). Fetal inflammation was defined as levels of IL-6 higher than 7.6 pg/ml. P/IVH was defined as early if diagnosed within the 1st day after birth; thereafter P/IVH was defined as late.

RESULTS

Adjusted for the influence of gestational age, early-onset sepsis (OR 3.2, p = 0.045) and no or incomplete antenatal steroid course (OR 6.0, p = 0.001) significantly predicted early P/IVH. Funisitis (OR 1.6, p = 0.06) and fetal inflammation (OR 2.6, p = 0.06) were only partially associated with early hemorrhage. Contrary to that, respiratory distress syndrome (OR 3.4, p = 0.04), mechanical ventilation (OR 5.9, p = 0.008), low blood pressure (OR 3.5, p = 0.02), and vasopressors (OR 5.7, p = 0.002) were associated with late P/IVH. In multivariate analysis no or incomplete steroid course remained independent predictors for early and use of vasopressors for late P/IVH. The interaction of fetal inflammation and vaginal delivery with no or incomplete steroid course increased the risk of early P/IVH.

CONCLUSIONS

These results indicate different risk factors for early and late P/IVH. Neither funisitis nor fetal inflammation independently predicts the onset of P/IVH. However, the interaction of fetal inflammation and vaginal delivery with no or incomplete antenatal steroid course increase the risk of early but not also late P/IVH.

The urinary activity of angiotensin-converting enzyme in preterm, full-term newborns, and children

The urinary activity of the angiotensin-converting enzyme (U(ACE)) is not yet completely documented in human neonates. We measured the U(ACE) in 36 premature neonates on the 1st day and in the 1st, 2nd, 3rd, and 4th weeks of life, in 22 full-term neonates between the 1st and 2nd days, and in 30 nursing and preschool children between 1 month and 6 years of age. The urinary excretion of sodium (U(Na)/U(Cr)) and the potassium/sodium index (U(K)/U(Na)) were analyzed in the neonates. U(ACE) was greater in premature than in full-term neonates and greater in both than in older children (p<0.001). In the premature neonates, U(ACE) peaked at the 2nd week, the U(Na)/U(Cr) index decreased, and the U(K)/U(Na) index increased between the 1st day and the 2nd week (p<0.001). The U(Na)/U(Cr) index on the 1st day and in the 1st and 2nd weeks was greater in premature than in full-term neonates (p<0.001). There was no significant correlation between the U(ACE) and the U(Na)/U(Cr) index. In conclusion, the U(ACE) profile was shown to be age dependent and related to the postnatal renal development. The increase in U(ACE) activity may reflect the high activity of the neonatal intrarenal renin-angiotensin system (RAS).

Guiding mothers' management of health problems of very low birth-weight infants

OBJECTIVE

Explore the feasibility, usefulness, and outcomes of a pilot program to support mothers in developing competencies for managing health problems of their very low birth-weight (VLBW) infants in partnership with the primary care clinician (PCC).

DESIGN

In a randomized study, mothers who received guided participation (GP) and printed guidelines for managing VLBW infant health problems were compared with mothers who received only the guidelines and standard care (GL group).

SAMPLE

All mothers (GP = 20; GL = 11) were at least 18 years old and English speaking. Infants were all VLBW (< or =1,500 g).

INTERVENTION

GP began during the infant's neonatal intensive care unit stay and continued with public health nurses (PHNs) and a family service clinician through the infant's first 4 postterm months.

MEASUREMENTS

Intervention feasibility and usefulness were assessed with maternal and clinician feedback. Outcomes included maternal and clinician appraisal of mothers' use of clinical resources and mothers' perceptions of primary-care quality and the family-PCC relationship.

RESULTS

Intervention feasibility and usefulness were supported. GP and GL groups did not differ significantly on outcomes.

CONCLUSIONS

Findings indicate a longer intervention period, GP organized by infant problem episodes, and enhancement of the PHN role in the context of interdisciplinary and interagency collaboration.

Pleural effusions in the neonate

INTRODUCTION

Pleural effusions are rare in the neonate and may be associated to several clinical conditions. Only a few series of pleural effusions in the fetus and newborn are described in the literature.

AIM

This study was undertaken to determine more accurately the causes and prognostic significance of pleural effusions in a population of high-risk neonates.

MATERIALS AND METHODS

A retrospective chart review of 62 neonates admitted to the neonatal intensive care unit of six medical centers in the north of Portugal, between 1997 and 2004, that presented the diagnosis of pleural effusion.

RESULTS

33M/29F newborns; preterms 47 (76%); GA 33 (25-40) wk; BW 1830 (660-4270) g; C-section 39 (63%). Pleural effusions were congenital in 20 (32%) newborns and acquired in 42 (68%). Congenital pleural effusions occurred as fetal hydrops in 11 (18%) patients and as chylothorax in 9 (15%). In four cases of hydrops, the cause was a congenital chylothorax. Congenital chylothorax (n=13) was the most common (65%) congenital pleural effusion in this study. The incidence of congenital chylothorax was 1:8.600 deliveries and male:female ratio was 2:1. Mortality occurred in five newborns due to pulmonary hypoplasia. Traumatic (iatrogenic) were the most frequent (n=31) acquired pleural effusions. These included 8 (13%) cases of hemothorax and 8 (13%) cases of total parenteral nutrition leakage. Pleural effusions after intra-thoracic surgery were mainly (79%) chylothoraces. There were 11 (26%) non-iatrogenic acquired pleural effusions. No mortality was associated with acquired pleural effusions.

CONCLUSIONS

Congenital pleural effusions usually occur as hydrops or congenital chylothorax. Traumatic (iatrogenic) are the most frequent acquired pleural effusions in a tertiary NICU. Pleural effusions after intra-thoracic surgery are mainly chylothoraces. Non-iatrogenic acquired pleural effusions are associated to several clinical conditions, and mortality is usually associated to the underlying condition.

Which phototherapy system is most effective in lowering serum bilirubin in very preterm infants?

OBJECTIVE

To compare the effectiveness of various phototherapy systems in lowering serum bilirubin levels in preterm infants.

METHODS

This randomized clinical trial enrolled 140 preterm infants with gestational age < or =30 weeks and presenting nonhemolytic hyperbilirubinemia. When total serum bilirubin level reached 6.0 mg/dl (102.6 micromol/l), eligible infants were randomly assigned to four study groups: conventional, fiberoptic Wallaby, fiberoptic Biliblanket, and combined phototherapy. Efficacy was assessed by comparing highest serum bilirubin levels, duration of treatment, and number of infants requiring exchange transfusion.

RESULTS

Our results confirm that fiberoptic phototherapy, both Wallaby and Biliblanket, had the same effectiveness of conventional phototherapy. The best results have been obtained using combined phototherapy, which allowed to reach lower serum bilirubin levels, a shorter duration of treatment and a significant reduction of exchange transfusions.

CONCLUSION

Our data suggest that combined phototherapy should be the method of choice in treating hyperbilirubinemia in very preterm infants.

Impact of gestational age on the clinical presentation and surgical outcome of necrotizing enterocolitis

OBJECTIVE

This investigation tests the hypothesis that the clinical presentation and the outcome of necrotizing enterocolitis (NEC) vary with gestational age (GA).

METHODS

All infants admitted to our center between October 1991 and September 2003 were evaluated weekly to identify confirmed cases of NEC. Based upon GA, these infants were divided into five groups: Extremely premature (EP, 23 to 26 weeks), very premature (VP, 27 to 29 weeks), moderately premature (MP, 30 to 34 weeks), near-term (NT, 35 to 36 weeks), and term (T, 37 to 42 weeks).

RESULTS

A total of 202 infants developed NEC. The most common sign of NEC among EP infants was ileus (77%), followed by abdominal distention (71%), emesis (58%), pneumoperitoneum (54%), fixed intestinal loop (52%), gasless abdomen (42%) and bloody stools (17%). Intramural gas was detected in 100% of T but was present in only 29% of EP infants (P < 0.0001). Similarly, portal venous gas was common in T but infrequent in the EP infants (47 vs 10%, P < 0.0001). Despite a higher peritoneal drain insertion rate (31 vs 5%, P < 0.001) and a higher mortality rate (33 vs 10%, P = 0.05) in EP compared to T infants, other clinical outcomes were not different.

CONCLUSIONS

The clinical presentation of NEC is different in EP compared to more mature infants; however, outcome among NEC survivors is similar across all GA. Reliance solely on observation of intramural or on portal venous gas in EP infants may lead to a delay or failure in the diagnosis.

Comparison of chronological and corrected ages in the gross motor assessment of low-risk preterm infants during the first year of life

OBJECTIVE: To evaluate the need of chronological age correction according to the degree of prematurity, when assessing gross motor development in preterm infants, during the first year of life. METHOD: Cohort, observational and prospective study. Alberta Infant Motor Scale (AIMS) was used to evaluate 43 preterm infants with low risk for motor neurological sequelae, during the first year of corrected age. Mean scores were analyzed according to chronological and corrected ages. Children with motor neurological sequelae were excluded during follow-up. RESULTS: Gross motor mean scores in preterm infants tended to be higher when corrected age was used compared with those obtained when using chronological age, during the first twelve months. At thirteen months of corrected age, an overlapping of confidence intervals between corrected and chronological ages was observed, suggesting that from that period onwards correction for the degree of prematurity is no longer necessary. CONCLUSION: Corrected age should be used for gross motor assessment in preterm infants during the first year of life.

Neonatal arterial hypertension in nephro-urological malformations in a tertiary care hospital

An increase in the survival of neonates with antenatal diagnosis of malformations was achieved by the recent technical advances in neonatal intensive care units. The aim of this article is to describe the experience with neonatal arterial hypertension, in newborns with nephro-urological malformations, in a tertiary care referral Nursery, in a period of 4 years. Newborn medical records from the Nursery Annex to the Maternity of Hospital das Clinicas, School of Medicine, University of Sao Paulo, with the diagnosis of nephro-urological malformations and systemic arterial hypertension (SAH) at hospital discharge, in a period from January 1999 to January 2003, were retrospectively analysed. Among 10.278 live newborns in the studied period, 15 (0.15%) newborns were compatible with our inclusion criteria. Of these 15 newborns, 12 (80%) were male and three were premature (20%). In relation to aetiology, 13 (87%) showed urological malformations, 1 (6%) chronic renal insufficiency secondary to kidney dysplasia and one (6%) autosomal recessive polycystic kidney disease. SAH control was achieved with monotherapy in eight patients (53%), five patients (33%) needed an association of two drugs (calcium-channel blocker and angiotensin converting enzyme (ACE) inhibitor), one child used three types of antihypertensive drugs (calcium-channel blocker, ACE inhibitor and hydrochlorothiazide) for pressoric control and one child's blood pressure (BP) was controlled exclusively by peritoneal dialysis. The incidence of nephro-urological malformations in our service during the studied period was 0.89%. SAH incidence among these newborns was 19%. Our data reinforce previous studies pointing to the necessity to consider children with nephro-urological malformations as a risk group for SAH, who should have the BP evaluated since the neonatal period.

Effect of preeclampsia on blood pressure in newborn very low birth weight infants

OBJECTIVE

To test the hypothesis that very low birth infants born to mothers with preeclampsia have higher blood pressure over the first week of life than infants whose mothers did not have preeclampsia.

METHOD

Infants born at<1,350 g who survived at least one week were stratified by gestational age ( <or= 28 weeks and >or= 29 completed weeks) and grouped by the presence or absence of preeclampsia. Highest and lowest systolic and mean and diastolic blood pressures were recorded for each of the first seven days of life. Serial blood pressures were analyzed by repeated measures ANOVA: The presence of hypertension (defined as >or= 3 days with the highest systolic blood pressure>90th percentile for gestational age stratum and day-specific range) was analyzed by binary logistic regression.

RESULTS

Infants >or= 29 weeks gestational age born to mothers with preeclampsia had higher blood pressures than did controls. Infants <or= 28 weeks gestational age born to preeclamptic and non-preeclamptic mothers had similar blood pressures. In the combined cohort, hypertension was not more prevalent among infants born to women with preeclampsia.

CONCLUSIONS

Preeclampsia is associated with higher blood pressure in very low birth weight neonates who are >or= 29 weeks gestation. The long-term significance of this finding is not known.

Bone, lean and fat mass of newborn twins versus singletons

AIM

Twin gestations are associated with disturbed fetal growth. The aim of this study was to compare body composition measurements of twins to those of singletons.

METHODS

Anthropometric and dual energy X-ray absorptiometry (DXA) measurements were performed in twins and in matched singleton neonates. There were 48 pairs of twins in which 76 infants were appropriate for gestational age (AGA) with birth weights between the 10th and 90th percentile and 20 were small for gestational age (SGA) with birth weights <10th percentiles. Each AGA twin was matched as closely as possible for birth weight to an AGA singleton. Each SGA twin was matched with two cohorts of AGA singletons: one with similar birth weight and one with similar gestation.

RESULTS

For AGA twins and their singleton cohort matched for birth weights, profile analysis using repeated measure analysis of variance showed that there were no significant differences in bone, fat and lean mass either as absolute values or as percentage of total weight. This was also the case for body composition of SGA twins compared to singletons matched for birth weight. In contrast, SGA twins have significantly lower absolute amounts of lean with tendency to lower fat and bone mass.

CONCLUSION

For clinically normally grown neonates, with comparable weight, the body composition with respect to bone, fat and lean mass components are similar regardless whether they are products of singleton or twin pregnancies.

Hypercapnia during the first 3 days of life is associated with severe intraventricular hemorrhage in very low birth weight infants

OBJECTIVE

To examine whether hypercapnia in very low birth weight (VLBW) infants during the first 3 days of life is associated with severe intraventricular hemorrhage (IVH).

STUDY DESIGN

Retrospective cohort study of inborn VLBW infants between January 1999 and May 2004 with arterial access during the first 3 days of life. A multiple logistic regression analysis was used where IVH was dichotomized ((grades 0/1/2) = non-severe; (grades 3/4) = severe). Measures of hypercapnia were entered into the model to ascertain their association with severe IVH.

RESULTS

In total, 574 VLBW infants met entry criteria. Worst IVH grade was 0 in 400; 1: 54; 2: 42; 3: 47; and 4: 31 infants. The logistic regression model consisted of the following predictors of severe IVH: gestational age, gender, 1 min Apgar score (dichotomized into two groups: >3 vs < or =3), multifetal gestation, vasopressor use, and maximum PaCO(2).

CONCLUSION

In addition to traditional risk factors, it appears maximum PaCO(2) is a dose-dependent predictor of severe IVH during the permissive hypercapnia era.

Are maternal re-infections with Trypanosoma cruzi associated with higher morbidity and mortality of congenital Chagas disease?

BACKGROUND

Comparing two surveys performed in Bolivia in 1992-1994 and 1999-2001, we reported a significant decrease in the proportions of severe and mortal forms of congenital Chagas disease. This might be due to a reduction of vectorial density (VD) in maternal residence area, raising the question of a possible causal relationship between such VD, maternal parasitaemia and prognosis of congenital infection with Trypanosoma cruzi.

METHOD

Comparisons of haematological and parasitological data obtained from Bolivian mothers infected with T. cruzi, and of clinical and biological data obtained from their infected and uninfected newborns, stratified according to VD in the area of maternal residence.

RESULTS

i) Blood hematocrit rates or hemoglobin amounts were within the normal ranges and similar in all the maternal groups, whatever the VD in their areas of residence; ii) mothers living in high VD areas displayed a higher frequency of hemocultures positive for T. cruzi; iii) newborns congenitally infected with T. cruzi, but not uninfected babies born from infected mothers, displayed higher frequencies of very low Apgar scores, low birth weights, prematurity, respiratory distress syndrome or anasarca, as well as higher mortality rates when their mothers lived in areas of high VD.

CONCLUSION

Frequent bites of blood sucking Reduvidae during pregnancy do not induce maternal anaemia, but, likely through multiple maternal re-infections with T. cruzi, increase maternal parasitemia and worsen congenital Chagas disease. Maternal dwelling in areas of high VD is associated with a serious increased risk of severe and mortal congenital Chagas disease.

Magnesium therapy in birth asphyxia

OBJECTIVE

Glutamate plays a critical role in the hypoxic ischaemic neuronal death. Two mechanisms of glutamate- induced neuronal death have been identified. One is rapid cell death that occurs in minutes and the second is delayed cell death that occurs over hours and is initiated principally by the activation of the N-methyl D-Aspactate (NMDA) receptor. Magnesium (Mg) is an NMDA receptor blocker. Systemic administration of Mg after a simulated hypoxic ischaemic insult has been shown to limit neuronal injury in several animal models. However, before embarking on to the use of Mg for neuronal protection in the human neonate it is important to study the safety and side effects of Mg administration.

METHODS

Forty terms, appropriate for gestational age babies with severe birth asphyxia (1 min Apgar score < 3 and 5 min Apgar score < 6), were randomly assigned to either the study group or the control group. Infants in both groups were treated as per unit protocol except that babies in the study group received intravenous injection of magnesium sulphate 250 mg/kg within half an hour of birth and subsequently 125 mg/kg at 24 and 48 hours of life.

RESULTS

The mean cord blood serum Mg levels were 0.78 (+/- 0.047) mmol/L in the control group and 0.779(+/-0.045) mmol/L in the study group. The serum Mg levels at 3, 6, 12, 24, 48 and 72 hours of life were 1.87(+/-0.6), 1.65(+/-0.059), 1.468 (+/-0.91), 1.881 (+/- 0.053), 1.916 (+/- 0.053) and 1.493 (+/- 0.084) mmol/L respectively in the study group. All these values were significantly higher than those obtained in the control group (p< 0.001). No significant alterations in heart rate, respiratory rate, oxygen saturation and mean arterial pressure were seen, following magnesium infusion with either 250 mg/kg or 125 mg/kg dose. The serum Mg levels in the study group ranged between 1.493 (+/- 0.084) and 1.916(+/-0.053) mmol/L, which are considered to be in the neuroprotective range.

CONCLUSION

Injection MgSO4 administered in a dose of 250 mg/kg and 125 mg/kg as an intravenous infusion is safe and the Mg levels obtained are in the range considered to be neuroprotective.

Increasing illness severity in very low birth weight infants over a 9-year period

Background

Recent reports have documented a leveling-off of survival rates in preterm infants through the 1990's. The objective of this study was to determine temporal changes in illness severity in very low birth weight (VLBW) infants in relationship to the outcomes of death and/or severe IVH.

Methods

Cohort study of 1414 VLBW infants cared for in a single level III neonatal intensive care unit in Delaware from 1993–2002. Infants were divided into consecutive 3-year cohorts. Illness severity was measured by two objective methods: the Score for Neonatal Acute Physiology (SNAP), based on data from the 1^st day of life, and total thyroxine (T₄), measured on the 5^th day of life. Death before hospital discharge and severe intraventricular hemorrhage (IVH) were investigated in the study sample in relation to illness severity. The fetal death rate was also investigated. Statistical analyses included both univariate and multivariate analysis.

Results

Illness severity, as measured by SNAP and T_4, increased steadily over the 9-year study period with an associated increase in severe IVH and the combined outcome of death and/or severe IVH. During the final 3 years of the study, the observed increase in illness severity accounted for 86% (95% CI 57–116%) of the variability in the increase in death and/or severe IVH. The fetal death rate dropped from 7.8/1000 (1993–1996) to 5.3/1000 (1999–2002, p = .01) over the course of the study.

Conclusion

These data demonstrate a progressive increase in illness in VLBW infants over time, associated with an increase in death and/or severe IVH. We speculate that the observed decrease in fetal death, and the increase in neonatal illness, mortality and/or severe IVH over time represent a shift of severely compromised patients that now survive the fetal time period and are presented for care in the neonatal unit.

Morbidity and mortality of infants born at the threshold of viability: ten years' experience in a single neonatal intensive care unit, 1991-2000

BACKGROUND

The purpose of the present paper was to evaluate the mortality and morbidity of infants born at 22-24 weeks gestation.

METHODS

A total of 78 infants born at 22-24 weeks gestation, who were admitted between January 1991 through December 2000, were retrospectively studied.

RESULTS

Seventy-one of 78 infants were enrolled in the present study. One year survival rates at 22, 23 and 24 weeks were 40.0% (2/5), 61.1% (11/18), and 50.0% (24/48), respectively. Failure of response to surfactant and air leak were associated with death in infants born at 23 weeks gestation. Low Apgar score, intraventricular hemorrhage (> or =III), and sepsis were correlated with death in infants born at 24 weeks gestation. The handicap rates of survivors born at 22, 23, and 24 weeks gestation were 100, 36.4, and 26.1%, respectively.

CONCLUSIONS

The present study indicates that infants born at 22 weeks gestation, in whom pulmonary structure is established, that is, a viable lung that can exchange gas with exogenous surfactant, have a chance to survive, but neurological outcome is still poor. Every possible effort should be made to extend gestation beyond 22 weeks.

Racial differences in prenatal care of mothers delivering very low birth weight infants

OBJECTIVES

To determine whether there are any racial differences in the prenatal care of mothers delivering very low birth weight infants (VLBW).

STUDY DESIGN

Retrospective cohort study of infants cared for at a single regional level III neonatal intensive care unit over a 9-year period, July 1993-June 2002, N = 1234. The main outcome variables investigated included antenatal administration of steroids, delivery by cesarean section, and use of tocolytic medications. Both univariate and multivariate analyses were performed.

RESULTS

After controlling for potential confounding variables, white mothers delivering VLBWs had an increased odds of cesarean delivery (odds ratio 1.5, 95% confidence intervals (CI) 1.1-2.0), receiving antenatal steroids (1.3, CI 1.01-1.8), and tocolysis (1.4, CI 1.1-2.0) compared to black mothers. The models controlled for gestational age, multiple gestation, premature labor, clinical chorioamnionitis, maternal age, income, year of birth, and presentation.

CONCLUSIONS

In our population of VLBWs, white mothers are more likely to receive antenatal steroids, tocolytic medications, and deliver by cesarean section when compared to black mothers. From our data we cannot determine the reasons behind these racial differences in care of mothers delivering VLBWs.

A double-blind, randomized, controlled study of a "stress dose" of hydrocortisone for rescue treatment of refractory hypotension in preterm infants

OBJECTIVE

To assess the effectiveness of a "stress dose" of hydrocortisone for rescue treatment of refractory hypotension and adrenocortical insufficiency of prematurity in very low birth weight (VLBW) infants. We hypothesized that significantly more VLBW infants who were receiving dopamine > or =10 microg/kg per min could wean off vasopressor support 72 hours after treatment with hydrocortisone.

METHODS

A double-blind, randomized, controlled study was conducted in a university neonatal center. Forty-eight VLBW infants who had refractory hypotension and required dopamine > or =10 microg/kg per min were randomly assigned to receive a stress dose of hydrocortisone (1 mg/kg every 8 hours for 5 days; n = 24) or an equivalent volume of the placebo solution (isotonic saline; n = 24).

RESULTS

The baseline clinical characteristics were similar between the groups. Serum cortisol concentrations were very low immediately before randomization in both groups of infants. Significantly more VLBW infants who were treated with hydrocortisone weaned off vasopressor support 72 hours after starting treatment. The use of volume expander, cumulative dose of dopamine, and dobutamine were significantly less in hydrocortisone-treated infants compared with control infants. In addition, the median duration of vasopressor treatment was halved in hydrocortisone-treated patients. Two versus 11 infants in the hydrocortisone and control groups required a second vasopressor for treatment of refractory hypotension. The trend (linear and quadratic) of the mean arterial blood pressure was also significantly and consistently higher in hydrocortisone-treated infants.

CONCLUSIONS

A stress dose of hydrocortisone was effective in treating refractory hypotension in VLBW infants. Although routine and prophylactic use of systemic corticosteroids could not be recommended because of their potential adverse effects, this relatively low dose of hydrocortisone would probably be preferable to high-dose dexamethasone for treatment of refractory hypotension in emergency and life-threatening situations.

Retinopatía del prematuro y estrés oxidativo

INTRODUCTION

There is some evidence that retinopathy of prematurity is due to excessive oxidative stress on the developing retina caused by high free radical production or reduced ability to eliminate these radicals.

OBJECTIVE

To determine the relationship between high levels of oxidative stress and retinopathy of prematurity.

MATERIAL AND METHODS

A prospective cohort study was designed. Fifty premature infants of less than 33 weeks' gestational age were included. Serum lipoperoxide levels were determined as a measure of oxidative stress. Samples were taken once a week for 1 month, starting from the first week of life. The results of all four samples were compared between infants who developed any degree of retinopathy of prematurity and those without it. Ophthalmological examinations were performed after the fourth week of life.

RESULTS

The incidence of retinopathy of prematurity was 22 % (11/50). The mean values of all the samples showed a significant difference between infants who developed retinopathy of prematurity (5.44 +/- 1.30 nmol/ml) and those who did not (2.94 +/- 0.89 nmol/ml, p = 0.0001). The relative risk of developing retinopathy of prematurity with high serum lipoperoxide levels was 5.15, 5.63, 4.15 and 12.70 for each of the weekly samples.

CONCLUSIONS

There is an association between high serum lipoperoxide levels, as a measure of oxidative stress, and the incidence of retinopathy of prematurity.

Polyethylene skin wrapping accelerates recovery from hypothermia in very low-birthweight infants

BACKGROUND

Thermal management of the very low-birthweight (VLBW) infant is a cornerstone of neonatology because thermal stress is an important determinant of survival. This prospective study was designed to determine the effects of polyethylene occlusive skin wrapping on heat loss in VLBW infants admitted to the neonatal intensive care unit (NICU) promptly after birth.

METHODS

Thirty consecutively inborn infants weighing <1500 g were allocated to a wrap or non-wrap group within an incubator after admission to the NICU. Axillary and incubator temperatures were taken on arrival at 1 and 2 h.

RESULTS

Infants in the wrap group reached a normal axillary temperature faster then non-wrap infants and required lower incubator temperatures.

CONCLUSIONS

Polyethylene film wrapping effectively helps to correct hypothermia in VLBW infants admitted to the NICU.

Valoración del test de Ballard en la determinación de la edad gestacional

BACKGROUND AND OBJECTIVES

The New Ballard Score (NBS) is commonly used to estimate gestational age (GA) in the newborn. The aims of this study were: a) to determine the reliability of the NBS; b) to estimate the agreement between two methods of GA assessment, NBS and ultrasonography (US) or last menstrual period (LMP); c) to estimate the agreement between NBS and US/LMP in distinct subgroups of neonates.

PATIENTS AND METHODS

We performed a prospective, blind study. NBS was performed in neonates born in Hospital 12 Octubre, Madrid before the age of 48 hours. The level of agreement was estimated with two analytical parameters: the intraclass correlation coefficient (ICC) and the mean differences method (MD).

RESULTS

Inter-observer agreement was very good (ICC > 0.8). Agreement between US/LMP and NBS was good (ICC = 0.6-0.8). In infants with lower weight or GA, and in those whose mothers had received prenatal corticosteroid therapy, NBS tended to overestimate GA compared with US/LMP (MD = 1.2-2.9).

CONCLUSIONS

The agreement between two observers in NBS assessment was very good. The agreement between NBS and US/LMP was good, but differences of more than 2 weeks in GA were frequent. In very preterm newborns and in infants whose mothers had received prenatal corticosteroid therapy, NBS tends to overestimate GA.

Limbs Anthropometry of Singleton Chinese Newborns of 28–42 Weeks’ Gestation

Abnormalities of limbs are important features of some syndromes recognizable at birth. The purpose of this study was to establish normal standards of limbs including arm length, arm circumference, upper arm length, lower arm length, leg length, thigh circumference, upper leg length, and lower leg length. 10,226 infants (5,422 males, 4,804 females) with gestation 28-42 weeks from 12 hospitals were included. The LMS method using maximum penalized likelihood was used to perform model fitting of the anthropometric centiles for these parameters. This study provided the first set of references for the limbs of the infants by gestation and gender. Racial differences were found when comparing with other populations. The parameters are useful for evaluation of morphologic disorders involving the limbs.

[Caffeine intake and food sources of caffeine and prematurity: a case-control study]

Caffeine (1,3,7-trimethylxanthine) is an alkali that easily crosses the placental barrier and can interfere in the growth and development of fetal cells and compromise fetal oxygenation. Considering the widespread consumption of foods containing caffeine in Brazil, the aim of this study was to evaluate the association between total caffeine consumption (including its food sources) and prematurity. A case-control study of 140 cases (newborns with gestational age less than 37 weeks) and 162 controls (newborns with 37 weeks gestational age or greater) evaluated caffeine consumption during pregnancy. Intake measurement used a semi-quantitative food frequency questionnaire based on the following foods: coffee, tea, and powdered chocolate. Total caffeine consumption (including food sources) during pregnancy was not associated with prematurity, and most intakes were less than 300 mg/ day. Caffeine consumption in the present study does not support guidelines against caffeine consumption by Brazilian pregnant women.

Communicating with parents of premature infants: who is the informant?

OBJECTIVES

To determine what sources of information are most helpful for neonatal intensive care unit (NICU) parents, who provides NICU parents with the information, and also what expectations parents have regarding obtaining information.

STUDY DESIGN

A 19-item questionnaire was given to the parents of infants 32 weeks or younger prior to discharge from the NICU.

RESULTS

Out of the 101 parents who consented, almost all of the parents (96%) felt that 'the medical team gave them the information they needed about their baby' and that the 'neonatologist did a good job of communicating' with them (91%). However, the nurse was chosen as 'the person who spent the most time explaining the baby's condition, 'the best source of information,' and the person who told them 'about important changes in their baby's condition' (P<0.01).

CONCLUSION

Although the neonatologist's role in parent education is satisfactory, the parents identified the nurses as the primary source of information.

The influence of gestational age and birth weight in the clinical assesment of the muscle tone of healthy term and preterm newborns

OBJECTIVE: To evaluate the influence of gestational age (GA) and birth weight (BW) in the clinical assessment of the muscle tone of healthy term and preterm newborns. METHOD: Cross sectional study. The muscle tone of healthy 42 preterm and 47 term newborns was quantified and measured with a goniometer (an instrument for measuring angles) respectively between 7th-14th day of life and 24-48 hours of life. Newborns were grouped according to GA and BW and evaluated at fixed time intervals by one examiner. Preterm newborns were matched to term at 40 weeks postconceptional age (PCA). RESULTS: The evolution of muscle tone in the preterm occurred gradually, following PCA, independent of birth weight. Preterm newborns had lower scores in all muscle tone indicators when compared to term at the first assessment. Differences were observed among preterm small for GA and adequate to GA for the indicator heel to ear (p<0.001). When compared at 40 weeks PCA, except for posture, all other indicators were significantly different (p< 0.001) among groups. CONCLUSION: Prematurity and intrauterine malnutrition are influential factors in some indicators of the newborn muscle tone state. Muscle tone assessment of preterm infants does not seem to be influenced by birth weight, however evolution is clearly related to postconceptional age. When we compared term newborns AGA and SGA it seems to have a clear influence of the birth weight on some indicators of the muscle tone. The use of devices such as the goniometer allows the performance of a more objective assessment of muscle tone and helps to quantify findings.

Reduced lung function in healthy preterm infants in the first months of life

RATIONALE

Preterm delivery has been associated with a higher incidence of respiratory morbidity even in infants that do not have significant respiratory disease during the neonatal period. Reduced flows have been reported in children and adolescents born prematurely.

OBJECTIVE

The aim of this study was to assess lung function in healthy preterm infants in the first months of life.

METHODS

Preterm infants with less than 48 h of supplemental oxygen were recruited. Lung function was assessed by the raised-volume rapid thoracic compression in the first months of life. The control group consisted of full-term infants without a history of respiratory diseases.

MEASUREMENTS AND MAIN RESULTS

Sixty-two preterm (29 male) and 27 full-term (10 male) infants were tested. Adjusting for length, age, and sex, we found a mean significant reduction of 92 ml/s (22%) in FEF(50), 73 ml/s (21%) in FEF(25-75), and 19 ml (28%) in FEV(0.5) in the preterm group. These differences in expiratory flows remained significant using another model that adjusts for lung volume (p < 0.01 for FEF(50), FEF(25-75), and FEV(0.5), and p < 0.05 for FEF(75)). In the preterm group, after adjusting for length, male sex, lower gestational age, and increased weight were significantly and independently associated with reduced flows.

CONCLUSIONS

Our findings confirm that prematurity is independently associated with reduced lung function and that this is detectable in the first months of life. Male sex, lower gestational age, and weight are important predictors for reduced expiratory flows in this group.

Deletion allele of angiotensin-converting enzyme is associated with increased risk and severity of bronchopulmonary dysplasia

OBJECTIVE

To explore whether the deletion (D) allele of angiotensin-converting enzyme (ACE) is associated with the risk or severity of bronchopulmonary dysplasia (BPD) among very low birth weight (BW) infants.

STUDY DESIGN

Infants with a BW < or = 1250 g were prospectively recruited. The D and I (insertion) alleles of ACE were determined using a polymerase chain reaction followed by restriction fragment length polymorphism analysis.

RESULTS

Infants with DD/DI genotype of ACE had a (mean +/- SD) birth weight (938 +/- 204 g vs 925 +/- 196 g) and gestational age (28 +/- 3 weeks vs 28 +/- 2 weeks), similar to infants with II genotype of ACE (P > .05). Infants with DD/DI genotype of ACE were more likely to have BPD than infants with II genotype (47% vs 22%, P = .025). Among infants with BPD, ACE DD/DI genotype was more common among infants with moderate or severe BPD compared with infants with mild BPD (74% vs 26%, P = .012). The number of D alleles of ACE correlated directly and positively with the severity of BPD (R = 0.23, P = .045).

CONCLUSION

The D allele of ACE is associated with an increased risk and severity of BPD among preterm infants.

A population-based study to determine the performance of the Cognitive Adaptive Test/Clinical Linguistic and Auditory Milestone Scale to Predict the Mental Developmental Index at 18 Months on the Bayley Scales of Infant Development-II in very preterm infants

OBJECTIVES

To determine optimal ages to perform the Cognitive Adaptive Test/Clinical Linguistic and Auditory Milestone Scale (CAT/CLAMS) and optimal "cutoff" score of the CAT/CLAMS to screen very preterm infants (<31 weeks) for severe cognitive-adaptive delay and to ascertain the sensitivity, specificity and likelihood ratios using optimal cutoff scores compared with the Mental Developmental Index (MDI) of the Bayley Scales of Infant Development II.

METHODS

A population-based cohort of very preterm infants who were born to mothers who resided in Nova Scotia or Prince Edward Island were evaluated at 4, 8, 12, and 18 months' corrected gestational age, which included a CAT/CLAMS by a physician. At 18 months' corrected gestational age, each child was assessed using the Bayley Scales of Infant Development II, the "gold standard" for developmental delay in young infants. The results of each CAT/CLAMS was compared with the 18-month MDI to identify significant developmental delay (MDI <70).

RESULTS

Optimal scores on the CAT/CLAMS to identify correctly MDI <70 were determined by using the kappa statistic for chance independent agreement. Sensitivities and specificities for optimal cutoff scores were as follows: 4-month score <109 (88% and 37%), 8-month score <98 (75% and 82%), 12-month score <81 (63% and 99%), and 18-month score <83 (88% and 98%).

CONCLUSION

Sensitivity and specificity of the CAT/CLAMS are high in very preterm infants at identifying major developmental delay at 12 and 18 months. For follow-up programs without psychology services, the CAT/CLAMS at 12 and 18 months is a reasonable screening tool to determine which children need expedited psychology referral for cognitive delay.

Risk factors for bronchopulmonary dysplasia in very low birth weight newborns treated with mechanical ventilation in the first week of life

The purpose of this study was to identify the risk factors for bronchopulmonary dysplasia (BPD) in a population of very low birth weight (BW) newborns treated with mechanical ventilation in the first week of life who survived the 28 days. The effects of antenatal steroids, sepsis, patent ductus arteriosus (PDA), fluid management and ventilator support strategies were investigated. This was a prospective study of a cohort of 86 newborns with BW below 1500 g who were born alive between the period of September 2000 to November 2002, treated at the University Hospital of Medical School Campinas, Brazil. The BPD was defined as the oxygen dependence in the 28 days, with consistent radiology findings. A logistic regression analysis was realized to identify the risk factors associated to BPD. Among the very low BW newborns, 45 developed BPD. The univariate analysis showed that besides BW and gestational age (GA), other factors such as FiO(2) > or = 0.60 (RR : 2.03; 95% CI: 1.4-2.94), PIP > or = 21 cm H(2)O (RR : 1.73; 95% CI: 1.12-2.65), surfactant therapy (RR : 1.68; 95% CI: 1.14-2.48), fluid volume on day 7 >131 ml/kg/day (RR : 1.81; 95% CI: 1.18-2.78), presence of PDA (RR : 1.95; 95% CI: 1.36-2.8) and pneumothorax (RR : 1.71; 95% CI: 1.18-2.45) were associated to an increase in the risk of BPD. When the variables were analysed concomitantly, using the multivariate logistic regression model, the most important risk factors for the development of BPD were GA < or = 30 weeks (RR : 2.76; 95% CI: 1.23-6.19), PIP > or = 21 cm H(2)O (RR : 1.92; 95% CI: 1.04-3.54), fluid volume on day 7 >131 ml/kg/day (RR : 2.09; 95% CI: 1.14-3.85) and presence of PDA (RR : 1.94; 95% CI : 1.03-3.65). The risk for BPD due to the association of these four factors was 96.4%. Finally, it was observed that the most important risk factors for BPD were prematurity, PDA and elevated levels of PIP as well as fluid volume.

Spinal motor neuron excitability in newborns following fetal distress: sub-clinical depression revealed by soleus H-reflex

OBJECTIVE

To explore possible spinal cord dysfunction in clinically unaffected newborns emerging from fetal distress, using H-Reflex.

METHODS

This cross-sectional study comprised 48 full-term newborn infants investigated between 8h and 10 days after birth. Twenty-one (21) had fetal distress defined by late-decelerations in fetal heart rate, out of which 11 had also meconium release in utero; 5 passed meconium in utero with normal FHR patterns; and 22 normal controls had uneventful birth. All had normal birth-weight and Apgar scores. All were found normal on neurological examination, except one showing hypotonia following fetal distress. Soleus H-reflex was studied in right lower limb.

RESULTS

Newborns delivered with fetal distress showed significant reduction in H-reflex excitability (H/M ratio) within 2 days of birth. Tests performed closer to the birth event revealed more severe depression. Meconium did not contribute to this effect.

CONCLUSIONS

Fetal distress can lead to transient, subclinical depression of spinal motoneurons in the newborn.

SIGNIFICANCE

This neonatal H-reflex study focuses on excitability of a spinal motoneuron pool rather than conduction parameters (reflecting myelination) available in literature. It reveals excitability changes missed on clinical examination of newborns apparently unaffected by intrapartum hypoxic-ischemic spells. It also draws attention towards spinal cord dysfunction in birth-hypoxia.

The role of serum and urinary urea in the evaluation of enteral protein intake in adequate and small-for-gestational-age very low birth weight infants

CONTEXT AND OBJECTIVE

Very low birth weight (VLBW) infants have special nutritional needs. There is a current tendency to individualize their protein needs. The objective of this study was to determine the suitability of serum and urinary urea as indicators for protein intake in adequate-for-gestational-age (AGA) and small-for-gestational-age (SGA) VLBW infants.

DESIGN AND SETTING

Prospective study in the nursery attached to the Maternity Ward of the "Prof. Pedro de Alcântara" Children's Institute, Hospital das Clínicas, Department of Pediatrics, Faculdade de Medicina da Universidade de São Paulo, Brazil.

METHODS

Seventy-two VLBW infants (mean protein intake = 3.7 mg/kg/day) were enrolled in a prospective cohort study in two groups: AGA (n = 34) and SGA (n = 38). Blood samples, six-hour urine (6hUr) collections and urine sample tests (STUr) were obtained for urea and creatinine assays at three and five weeks of life.

STATISTICAL ANALYSIS

Student's t test, Pearson correlation and linear regression (p < 0.05).

RESULTS

There were no differences between groups for serum urea, 6hUr and STUr, or between two assessments within each group. Serum urea correlated with 6hUr in both AGA and SGA, and to STUr in SGA; 6hUr correlated with STUr in both AGA and SGA. There was no correlation between protein intake and serum or urine urea.

CONCLUSIONS

Serum and urinary urea did not reflect protein intake when mean intakes of 3.7 g/kg/day were used. Sample tests of urinary urea can be as reliable as urea from urine collected over longer periods.

Hydrocephalus after intraventricular hemorrhage in preterm and low–birth weight infants: analysis of associated risk factors for ventriculoperitoneal shunting

BACKGROUND

Intraventricular hemorrhage and posthemorrhagic hydrocephalus are common causes of neonatal morbidity and mortality among preterm and low-birth weight infants (PT-LBWIs). Clinical management of posthemorrhagic hydrocephalus (PHH) is difficult and not well standardized. In this study, we aimed to determine the incidence of hydrocephalus after intraventricular hemorrhage (IVH) and the associated risk factors for ventriculoperitoneal (V-P) shunting in PT-LBWIs. We also aimed to identify the medical-care practices for these babies.

METHODS

We reviewed the medical records of 42 babies with IVH diagnosed by cranial ultrasonography (classification of Papile et al, J Pediatr 1978;92:529-34). We compared 11 babies who required a V-P shunt with the 31 control subjects who did not require a V-P shunt or who died before discharge with respect to risk factors involved in V-P shunting. Maternal, perinatal, and neonatal risk factors, and therapies for IVH and PHH were studied as the V-P shunt-associated risk factors.

RESULTS

The mean gestational age studied was 28.9 +/- 2.7 weeks, and the mean birth weight was 1164 +/- 391 g. This study revealed an incidence of 26% of PHH in PT-LBWIs with IVH. The most important risk factor for V-P shunt was found to be the severity of IVH (P < .05). Late gestational age and the time of IVH were found to be significant as well (P < .05). The length of hospitalization was found to be longer in patients with V-P shunt (P < .05). Therapies used for IVH and/or PHH were not significant as a risk factor for V-P shunt. In addition, the mortality rate was found to be 38% for all patients with IVH.

CONCLUSION

Intraventricular hemorrhage in PT-LBWIs remains a significant problem, particularly when it is associated with PHH leading to long-term neurological impairment and decreased survival rate.

[Neonatal morbidity and mortality according to intrauterine growth pattern]

OBJECTIVE

To evaluate the influence of intrauterine growth on neonatal morbidity and mortality in live neonates born in a regional tertiary care center.

PATIENTS AND METHODS

A retrospective cohort study was performed. Data from 12,311 live neonates (LN) born in our hospital (from January 1999 to December 2003) were reviewed to analyze neonatal morbidity and mortality according to whether the LN were appropriate (AGA), small (SGA) or large (LGA) for gestational age. The variables collected from birth to hospital discharge were: gestational abnormalities, gender, delivery type, Apgar score, respiratory distress, presentation of obstetric trauma (including cephalohematomas), hypoglycemia, hypocalcemia, hyperbilirubinemia, congenital malformations, heart disease, and type of hospital discharge. Differences were examined among groups. We used the chi-squared test to compare the frequency of these variables in each group.

RESULTS

Data from 12,311 LN were entered into the database; 11,182 (90.8%) were AGA, 743 (6.1%) were LGA and 386 (3.1%) were SGA. There were 52.58% boys and 47.42% girls, and 5.5% of LN had macrosomia (birth weight > 4,000 g). A total of 0.39% of LN died before hospital discharge. Among LN, there were 1,215 preterm infants, representing 9.89% of all LN and 2.63% died (SGA 25% and AGA 75%). There was a prevalence of boys in the LGA group and of girls in the SGA group (p = 0.000). The presence of maternal diabetes (pregestational or gestational) was significantly higher (p = 0.000) in the LGA group. Maternal hypertension, smoking and drug addiction were significantly higher in the SGA group. The finding of obstetric trauma was significantly higher in the LGA group (p = 0.000). The proportion of congenital malformations, hypocalcemia and hypoglycemia was higher in the SGA group than in the AGA and LGA groups (p = 0.000). Neonatal mortality was significantly higher (p = 0.000) in the SGA group and preterm infants.

CONCLUSIONS

Neonates with deviations in the pattern of intra-uterine growth had worse outcome. Prognosis was worse in SGA neonates, followed by LGA neonates, than in AGA neonates.

Infants with intrauterine growth restriction have impaired formation of docosahexaenoic acid in early neonatal life: a stable isotope study

This study evaluated the arachidonic acid (AA) and docosahexaenoic acid (DHA) formation from d5-labeled linoleic acid (d5-LA) and alpha-linolenic acid (d5-LNA) precursors in infants with intrauterine growth restriction (IUGR) compared with control groups matched by gestational age (GA) or birth weight. We compared DHA and AA formation from deuterated precursors d5-LA and d5-LNA in 11 infants with IUGR with 13 and 25 control subjects who were appropriate for GA and matched by GA and by birth weight, respectively. After an enteral administration of d5-LA and d5-LNA, we determined unlabeled and d5-labeled fatty acids at 24, 48, and 96 h in plasma. Absolute concentrations and area under the curve (AUC) over the 96-h study were used for analysis. Absolute concentration of d5-DHA and the product/precursor ratio of the d5-labeled AUCs indicated a less active DHA formation from LNA in infants with IUGR compared with their GA-matched (2-fold) and birth weight-matched (3-fold) control subjects. The ratios of eicosapentaenoic and n-3 docosapentaenoic acid to DHA were also affected. Similar evaluation for the n-6 series was not significant. DHA metabolism is affected in infants with IUGR; the restricted DPA to DHA conversion step seems to be principally responsible for this finding.

Principles and practices of neurodevelopmental assessment in children: lessons learned from the Centers for Children's Environmental Health and Disease Prevention Research

Principles and practices of pediatric neurotoxicology are reviewed here with the purpose of guiding the design and execution of the planned National Children's Study. The developing human central nervous system is the target organ most vulnerable to environmental chemicals. An investigation of the effects of environmental exposures on child development is a complex endeavor that requires consideration of numerous critical factors pertinent to a study's concept, design, and execution. These include the timing of neurodevelopmental assessment, matters of biologic plausibility, site, child and population factors, data quality assurance and control, the selection of appropriate domains and measures of neurobehavior, and data safety and monitoring. Here we summarize instruments for the assessment of the neonate, infant, and child that are being employed in the Centers for Children's Environmental Health and Disease Prevention Research, sponsored by the National Institute of Environmental Health Sciences and the U.S. Environmental Protection Agency, discuss neural and neurobiologic measures of development, and consider the promises of gene-environment studies. The vulnerability of the human central nervous system to environmental chemicals has been well established, but the contribution these exposures may make to problems such as attention deficit disorder, conduct problems, pervasive developmental disorder, or autism spectrum disorder remain uncertain. Large-scale studies such as the National Children's Study may provide some important clues. The human neurodevelopmental phenotype will be most clearly represented in models that include environmental chemical exposures, the social milieu, and complex human genetic characteristics that we are just beginning to understand.

Resistin in preterm and term newborns: relation to anthropometry, leptin, and insulin

This study aimed to investigate 1) the plasma resistin concentration at birth, 2) the relationship of resistin with leptin and insulin, and 3) the association of resistin with anthropometric indexes in newborn infants. Blood samples for hormonal assay were obtained from preterm and term newborns within the first 2 h of life and before milk feeding or energy intake. Although these infants required blood sampling for clinical reasons, all were proved to be noninfected. Plasma resistin was significantly higher in term than in preterm infants. It was also significantly correlated with serum leptin, and both hormones were significantly associated with gestational age and anthropometric indexes. Infants who were born vaginally were found to have significantly higher plasma resistin levels compared with those who were born by cesarean section. In the multivariate forward stepwise regression models, resistin was found to be significantly associated with the mode of delivery and gestational age or birth weight. The association among resistin, leptin, and anthropometric indexes suggested that both hormones might be gestation related. A high circulating resistin level at term gestation could be advantageous to the infant by promoting hepatic glucose production and preventing hypoglycemia after birth. Infants who were born vaginally had significantly higher plasma resistin levels, suggesting that this hormone might also be associated with stress or inflammation induced by the birth process.

Trunk anthropometry of Hong Kong Chinese infants

BACKGROUND

Disturbed growth of the trunk may result in abnormal sternocostal relationship and a variety of pectus deformities.

AIMS

The purposes of this study were to establish norms of trunk anthropometry for dysmorphology identification in the newborns and to evaluate chest circumference as a predictor for low birth weight for outborn infants where weighing scales were unavailable.

STUDY DESIGN AND SUBJECTS

A total of 10,339 Chinese infants (5478 males, 4861 females) with gestation 24-42 weeks from 12 hospitals were included. The anthropometric measurements analyzed included chest circumference, inter-nipple distance, sternal length and abdominal circumference.

OUTCOME MEASURES

The LMS method using maximum penalized likelihood was used to perform model fitting of the anthropometric centiles for these physical parameters.

RESULTS

References tables of the four physical parameters for newborns were constructed. Chest circumference showed the highest correlation with birth weight (male: r = 0.866, female: r = 0.883). The cut-off points for chest circumference of 295 (male) and 299 mm (female) were the best predictor for low birth weight. There were also racial differences in these parameters. When compared with French infants, Chinese newborns had smaller chest circumference.

CONCLUSION

These physical parameters provide useful references and aid dysmorphology diagnosis in newborns of ethnic Chinese origin.

Umbilical cord blood and neonatal endothelin-1 levels in preterm newborns with and without respiratory distress syndrome

Increased pulmonary vascular resistance in preterm newborn infants with respiratory distress syndrome is suggested, and endothelin-1 plays an important role in pulmonary vascular reactivity in newborns. We determined umbilical cord blood and neonatal (second sample) levels of endothelin-1 in 18 preterm newborns with respiratory distress syndrome who had no clinical or echocardiographic diagnosis of pulmonary hypertension and 22 without respiratory distress syndrome (gestational ages: 31.4 +/- 1.6 and 29.3 +/- 2.3 weeks, respectively). Umbilical cord blood and a second blood sample taken 18 to 40 h after birth were used for endothelin-1 determination by enzyme immunoassay. Median umbilical cord blood endothelin-1 levels were similar in both groups (control: 10.9 and respiratory distress syndrome: 11.4 pg/mL) and were significantly higher than in the second sample (control: 1.7 pg/mL and respiratory distress syndrome: 3.5 pg/mL, P < 0.001 for both groups). Median endothelin-1 levels in the second sample were significantly higher in children with respiratory distress syndrome than in control infants (P < 0.001). There were significant positive correlations between second sample endothelin-1 and Score for Neonatal Acute Physiology and Perinatal Extension II (r = 0.36, P = 0.02), and duration of mechanical ventilation (r = 0.64, P = 0.02). A slower decline of endothelin-1 from birth to 40 h of life was observed in newborns with respiratory distress syndrome when compared to controls. A significant correlation between neonatal endothelin-1 levels and some illness-severity signs suggests that endothelin-1 plays a role in the natural course of respiratory distress syndrome in preterm newborns.

Malaria during pregnancy and foetal haematological status in Blantyre, Malawi

BACKGROUND

Although maternal anaemia often stems from malaria infection during pregnancy, its effects on foetal haemoglobin levels are not straightforward. Lower-than-expected cord haemoglobin values in malarious versus non-malarious regions were noted by one review, which hypothesized they resulted from foetal immune activation to maternal malaria. This study addressed this idea by examining cord haemoglobin levels in relation to maternal malaria, anaemia, and markers of foetal immune activation.

METHODS

Cord haemoglobin levels were examined in 32 malaria-infected and 58 uninfected women in Blantyre, Malawi, in relation to maternal haemoglobin levels, malaria status, and markers of foetal haematological status, hypoxia, and inflammation, including TNF-alpha, TGF-beta, and ferritin. All women were HIV-negative.

RESULTS

Although malaria was associated with a reduction in maternal haemoglobin (10.8 g/dL vs. 12.1 g/dL, p < 0.001), no reduction in cord haemoglobin and no significant relationship between maternal and cord haemoglobin levels were found. Cord blood markers of haematological and hypoxic statuses did not differ between malaria-infected and uninfected women. Maternal malaria was associated with decreased TGF-beta and increased cord ferritin, the latter of which was positively correlated with parasitaemia (r = 0.474, p = 0.009). Increased cord ferritin was associated with significantly decreased birth weight and gestational length, although maternal and cord haemoglobin levels and malaria status had no effect on birth outcome.

CONCLUSION

In this population, cord haemoglobin levels were protected from the effect of maternal malaria. However, decreased TGF-beta and elevated ferritin levels in cord blood suggest foetal immune activation to maternal malaria, which may help explain poor birth outcomes.

Ghrelin in preterm and term newborns: relation to anthropometry, leptin and insulin

AIMS

This study aimed to investigate (i) the plasma ghrelin concentration at birth, (ii) the relationship of ghrelin with metabolic hormones, including leptin and insulin, and (iii) its association with anthropometric parameters, in appropriately grown preterm (23-36 weeks gestation) and term (37-42 weeks gestation) newborns.

PATIENTS AND METHODS

Blood samples for hormonal assay were obtained from preterm (n = 81) and term newborns (n = 40) within the first 2 h of life and before milk feeding or energy intake. The relationship between plasma ghrelin and other metabolic hormones or anthropometric parameters was evaluated.

RESULTS

Plasma ghrelin was detectable in all studied infants and the concentrations did not differ significantly between term and preterm infants [median (interquartile range): 1.21 (0.86-1.48) nmol/l vs. 1.04 (0.71-1.51) nmol/l, P = 0.52, respectively]. There was no overall significant correlation between plasma ghrelin and gestational age, anthropometric parameters and leptin or insulin. However, when term and preterm infants were analysed independently, plasma ghrelin was inversely correlated with birth weight (r = -0.31, P = 0.05) and body length (r = -0.33, P = 0.04) in the term infant group.

CONCLUSIONS

Our findings suggested that plasma ghrelin concentrations were relatively constant at birth, between 23 and 42 weeks gestation, and ghrelin secretion did not appear to undergo gestational age-related variations. An inverse relationship between plasma ghrelin and anthropometric indices in term infants raised the possibility that ghrelin might adopt its physiological role in regulating growth and metabolism at a late stage of gestation (> or = 37 weeks gestation). This phenomenon could be beneficial to term newborns by stimulating their appetite and maintaining an adequate blood sugar level at the most critical period when nutrients from mothers are abruptly terminated after birth.