New Ballard Score, expanded to include extremely premature infants

Effect of guided participation on feeding competencies of mothers and their premature infants

The effect of guided participation (GP) on premature infant and maternal feeding competencies was examined, controlling for infant, maternal, and family conditions. Competencies were examined longitudinally and within age (1, 4, 8, and 12 months post-term age) for 42 mother-infant pairs randomly assigned to either GP or Standard Care (SC) groups. The hypothesized GP effect on competencies across infant age received support for infants (at 1 and 8 months) and for mothers (at 4 months). The hypothesized contribution of conditions was most strongly supported by the negative relationship between family poverty status and the two maternal competency variables. The hypothesized GP moderator effect on the relationship between depressive symptoms and maternal competency variables was supported for regulation of negative affect and behavior at 8 months. Despite study limitations in power and sensitivity to detect effects, findings indicate that further study of the GP intervention is merited.

Comparison of serum cardiac troponin T and creatine kinase MB isoenzyme mass concentrations in asphyxiated term infants during the first 48 h of life

OBJECTIVE

This prospective study aimed to compare serum creatine kinase MB isoenzyme (CK-MB) mass concentrations and cardiac troponin T (cTnT) concentrations during the first 48 h of life in asphyxiated term infants.

METHODS

Serum cTnT and CK-MB mass concentrations of 50 term infants with clinical features of perinatal asphyxia were measured at birth and at 12, 24 and 48 h of age by chemiluminescence immunoassay. These infants were followed up until discharge or death. Cord blood CK-MB and cTnT concentrations of 50 healthy term infants were also assayed.

RESULTS

At birth, asphyxiated infants had significantly higher concentrations of cTnT and CK-MB than controls (P < 0.0001). Serum cTnT of asphyxiated infants with low ejection fraction <60% was significantly higher at 12 and 24 h than those with normal ejection fraction (P < 0.05). Asphyxiated infants with congestive cardiac failure had significantly higher serum cTnT concentration during the first 48 h of life than those without congestive cardiac failure (P <or= 0.04). Serum cTnT concentrations during the first 48 h of life were significantly higher in asphyxiated infants who died than those who survived (P < 0.0001). There was no significant difference in serum CK-MB mass concentrations between asphyxiated infants with and without these complications (P >or= 0.1).

CONCLUSION

Unlike CK-MB, serum cTnT concentrations are significantly higher in asphyxiated infants who die or develop cardiac dysfunction.

Effect of Two Amino Acid Solutions on Leucine Turnover in Preterm Infants

OBJECTIVE

To assess the effect of two different parenteral amino acid mixtures, Trophamine and Primene, on leucine turnover in preterm infants.

METHOD

Leucine kinetics were measured with [5,5,5 D3]leucine tracer in 15 infants receiving Trophamine (group 'T') (mean birth weight 1,263 g) and 22 who received Primene (group 'P') (mean birth weight 1,336 g) during two study periods, within a few hours after birth but before introduction of parenteral amino acid solution, and again at postnatal day 7. The rate of appearance of leucine was calculated from the enrichment of alpha-ketoisocaproic acid in plasma.

RESULTS

There were no significant differences in leucine turnover within a few hours after birth in the two groups. In the infants who received Primene leucine turnover on day 7 was significantly lower than in those who received Trophamine (269 +/- 43 vs. 335 +/- 27, p < 0.05). Despite a higher intake of leucine in the Trophamine group (108 +/- 10 vs. 77 +/- 8 micromol.kg(-1).h(-1)), leucine released from proteins at day 7 was higher in this group compared to Primene (227 +/- 27 vs. 192 +/- 42 micromol.kg(-1).h(-1)).

CONCLUSIONS

Primene administration results in lower leucine released from proteins, an estimate of protein breakdown, than Trophamine in preterm infants. Increases in whole body leucine turnover in response to administration of i.v. amino acids is influenced by the composition of the amino acid mixture. The factors responsible for this difference remain to be elucidated.

Normative Data of Penile Length for Term Chinese Newborns

Careful examination and assessment of penile length in the newborn is important because micropenis is associated with hypothalamic disorders. This prospective cross-sectional study was designed to establish the norm of penile length for term Hong Kong Chinese newborns. 4,628 full-term healthy male newborns were enrolled in the study. Penile length was measured from pubic ramus to the tip of the glans penis by placing the end of a straight edge ruler against the pubic ramus. A gestation-associated graph of 3rd, 10th, 25th, 50th, 75th, 90th and 97th centiles for the penile length was created. The penile length was significantly correlated with gestational age, birth weight and body length. When compared with published data for other populations, Hong Kong newborns have significantly shorter penile length. The norm of the penile length is useful in diagnostic and therapeutics for the ethnic Chinese male newborns.

Pregnancy outcome for Rh-alloimmunized women

OBJECTIVE

To compare perinatal results of Rh-alloimmunized pregnancies managed with spectrophotometric amniotic fluid analysis or fetal middle cerebral artery Doppler ultrasonographic velocimetry.

METHOD

A descriptive observational study involving 291 consecutive Rh-negative pregnancies. Group 1 consisted of 74 isoimmunized women managed with amniotic fluid spectrophotometry; group 2 of 25 isoimmunized women managed with Doppler ultrasonography; and group 3 of 192 nonimmunized Rh-negative women. The variables analyzed were need for intrauterine or neonatal transfusion, mode and time of delivery, birth weight, neonatal hematocrit, and perinatal mortality.

RESULTS

Need for intrauterine transfusion, birth weight, prematurity, rate of cesarean section, and perinatal mortality were similar in groups 1 and 2. Neonatal hematocrit was significantly lower and the need for neonatal transfusion was significantly higher when spectrophotometry rather than Doppler ultrasonographic velocimetry was used.

CONCLUSION

Fetuses managed with Doppler ultrasonographic velocimetry had a higher hematocrit at birth and a lesser need for neonatal transfusion, suggesting that this noninvasive method of monitoring fetal anemia is a better choice.

Effect of bathing on skin flora of preterm newborns

OBJECTIVE

To assess the effect of bathing with water only or with mild pH neutral soap and water on skin flora of preterm newborns.

METHOD

Randomized blinded clinical trial that enrolled 73 preterm newborns whose gestational age was between 28 and 35 weeks and birth weight between 800 and 1800 g. At the age of 3 days the infants were randomly assigned to a group that was given daily baths either with water only, or with soap and water for 7 or more days. Antibiotic treatment delayed onset of the trial in some preterm infants. On the final day of bathing axillary bacterial cultures were obtained before and 30 minutes after bathing.

RESULTS

At the time of axillary culturing, the mean age of the newborns was 19 days. Coagulase-negative Staphylococcus was the most prevalent microorganism in both groups. No significant difference was found in the count of microorganism colonies between both groups. The comparison of the number of bacterial colonies between the time before and after bath, carried out by repeated-measures ANOVA showed a significant difference over time in the two groups, without a significant difference between the two groups.

CONCLUSIONS

Bathing preterm newborns with water only or with soap and water produces similar effects on skin colonization of a preterm neonate. Both are effective to decrease the number of colonies of Gram-positive and Gram-negative bacteria.

Infection control practices reduce nosocomial infections and mortality in preterm infants in Bangladesh

OBJECTIVE

The skin is a potential source for invasive infections in neonates from developing countries such as Bangladesh, where the level of environmental contamination is exceedingly high. A randomized controlled trial was conducted from 1998 to 2003 in the Special Care Nursery of a tertiary hospital in Bangladesh to test the effectiveness of topical emollient therapy in enhancing the skin barrier of preterm neonates less than 33 weeks of gestational age. In the initial months of the study, the infection and mortality rates were noted to be unacceptably high. Therefore, an infection control program was introduced early in the trial to reduce the rate of nosocomial infections.

STUDY DESIGN

After a comprehensive review of neonatal care practices and equipment to identify sources of nosocomial infections, a simple but comprehensive infection control program was introduced that emphasized education of staff and caregivers about measures to decrease risk of contamination, particularly hand-washing, proper disposal of infectious waste, and strict asepsis during procedures, as well as prudent use of antibiotics.

RESULTS

Infection control efforts resulted in declines in episodes of suspected sepsis (47%), cases of culture-proven (61%) sepsis, patients with a clinical diagnosis of sepsis (79%), and deaths with clinical (82%) or culture-proven sepsis (50%).

CONCLUSION

The infection control program was shown to be a simple, low-cost, low-technology intervention to reduce substantially the incidence of septicemia and mortality in the nursery.

Gestational age, sex and maternal parity correlate with bone turnover in premature infants

Factors affecting bone turnover in premature infants are not entirely clear but certainly are different from those influencing bones of adults and children. To identify fetal and maternal factors that might influence bone turnover, we prospectively studied 50 infants (30 preterm and 20 full-term) born at Ain Shams University Obstetric Hospital in Cairo, Egypt. Maternal parity and medical history and infant's weight, gestational age, gender and anthropometrical measurements were recorded. Cord blood samples were collected and serum type I collagen C-terminal propeptide (PICP) was assessed as a marker for fetal bone formation. First morning urine samples were collected and pyridinoline cross-links of collagen (Pyd) were measured as an index for bone resorption. Serum PICP was higher in premature infants when compared with full-term infants (73.30 +/- 15.1 versus 64.3 +/- 14.7, p = 0.022) and was higher in male premature infants when compared with females (81.64 +/- 9.06 versus 66.0 +/- 15.7, p = 0.018). In a multiple regression model using PICP as the dependent variable and controlling for different infant and maternal conditions, PICP significantly correlated with infant gender (r = 8.26 +/- 4.1, p = 0.05) maternal parity (r = -2.106 +/- 0.99, p = 0.041) and diabetes (r = 22.488 +/- 8.73, p = 0.041). Urine Pyd tended to increase in premature infants (612 +/- 308 versus 434 +/- 146, p = 0.057) and correlated significantly with gestational age (r = -63.93 +/- 19.55, p = 0.002). Therefore, bone formation (PICP) is influenced by fetal age and gender, as well as maternal parity and diabetes. Bone resorption (Pyd) is mostly dependent on gestational age only. Further in-depth studies are needed to enrich management of this vulnerable population.

Using computer vision to help the determination of the gestational age of newborns

RATIONALE AND OBJECTIVES

This report presents a computational approach to help the gestational age determination of newborns. Gestational age knowledge is fundamental to guide postnatal treatment and increase survival chances of newborns. However, current methods are invasive and do not generate precise results, mainly because they were developed based on nonpremature populations.

MATERIALS AND METHODS

We developed an original and noninvasive method to help determination of gestational age based on information supplied by plantar surface images. These images present many details and patterns, but, to date, have not received attention from the image-processing community. We provide a computational tool with suitable facilities to allow the image analysis, either automatically or user driven. This image-processing tool is presented here.

RESULTS

The image-processing tool was developed on a user-driven basis. However, as a quantitative experiment, 186 images were processed without user intervention to observe tool behavior in performing different tasks. Although preliminary, experimental results confirm the relationship between plantar surface features and gestational age.

CONCLUSION

A prototype of the FootScanAge System is being used and evaluated by experts in neonatology. By means of digital processing of plantar surface images, some characteristics may be shown. Some hypotheses regarding the method have already been confirmed. Also, we show that some well-known image-processing techniques, if appropriately adapted, lead to suitable results when applied to plantar surface images.

The impact of vaginal delivery in premature infants weighing less than 1,251 grams

OBJECTIVE

To evaluate whether mode of delivery is a predictor of poor short-term outcome at different birth weight categories in very low birth weight infants.

METHODS

This study examined a cohort of infants weighing less than 1,251 g born at 2 perinatal centers from January 1, 2000, to December 31, 2003. Outborn infants or those with major anomalies were excluded from the study. Outcome variables included death, severe intraventricular hemorrhage, periventricular leukomalacia (PVL), and combined poor short-term outcomes (death, severe intraventricular hemorrhage, and PVL).

RESULTS

Of the 397 infants who met enrollment criteria, 44% were born vaginally and 56% by cesarean delivery. The proportion of multiparous, breech presentation and prolonged rupture of membranes was significantly different between groups. For infants weighing less than 751 g, the risks of severe intraventricular hemorrhage (41% versus 22%; odds ratio [OR] 2.79, 95% confidence interval [CI] 1.08-7.72) and combined poor short-term outcome (67% versus 41%; OR 2.95, 95% CI 1.25-6.95) were significantly higher if delivered vaginally. Among survivors weighing less than 751 g, the risk of severe intraventricular hemorrhage was higher among those delivered vaginally (24% versus 9%; OR 8.18, 95% CI 1.58-42.20). In infants less 1,251 g who survived, vaginal delivery had a strong association with PVL (5% versus 1%; OR 11.53, 95% CI 1.66-125).

CONCLUSION

In infants less than 1,251 g who survived to discharge, vaginal delivery is associated with higher risk for PVL. Furthermore, in infants less than 751 g, vaginal delivery is a predictor for severe intraventricular hemorrhage and combined poor short-term outcome. The negative impact of vaginal delivery mode decreases as birth weight category increases.

The premie-neuro: a clinical neurologic examination of premature infants

PURPOSE

To develop a neurologic assessment tool, the Premie-Neuro, for very low birth weight (VLBW) infants. INSTRUMENT DEVELOPMENT: Neurologic data were collected during the coursc of the NICU stay. Factor analysis was utilized to determine the strength of relationships between items and to reduce the initial number of test items.

SAMPLE

An NICU cohort of 86 preterm infants was enrolled. Mean birth weight was 1165.8 +/- 446.7 grams, and mean gestational age at birth was 28.8 +/- 3.2 weeks.

METHOD

Seventy-five neurologic and behavioral characteristics were assessed in week 1 of life and every 2 weeks thereafter until 38 weeks posreonceprional age.

MAIN OUTCOME VARIABLE

Three factors, the Neurologic Scale, the Movement Scale, and the Responsiveness Scale, described the neurologic examination.

RESULTS

Factor reliability was calculated for internal consistency (Cronbach alpha coefficient) and ranged from .73 to .82. The Premie-Neuro can be utilized with VLBW infants to monitor neurologic development during NICU care.

Effects of corticosteroids in very low birth weight newborns dependent on mechanical ventilation

Corticosteroids have been used in bronchopulmonary dysplasia prevention because of their antiinflammatory effects. Among their effects is a decrease in the incidence of bronchopulmonary dysplasia. However, short- and long-term side effects have been detected in preterm newborns.

PURPOSE

To analyze the effects of corticosteroids on bronchopulmonary dysplasia, length of stay, mortality, growth, as well as the adverse effects in very low birth weight newborns between 10 and 14 days of life and dependent on mechanical ventilation.

METHODS

Cohort study. All newborns with a birth weight under 1500 g, mechanical ventilation-dependent between 10 and 14 days of life, during the period January 2000 and June 2001 were included (n = 38). They were divided into 2 groups: Group I with corticosteroids (n = 16) and Group II without corticosteroids (n = 22). Dexamethasone administration: from the 10th day of life, d1-d3, 0.3 mg/kg/d; d4-d6, 0.2 mg/kg/d; d7-d9, 0.1 mg/kg/d. Respiratory evolution, bronchopulmonary dysplasia (oxygen dependence at 28 days of life), growth pattern and the presence of adverse effects were analyzed.

RESULTS

The incidence of bronchopulmonary dysplasia was 6.5% (Group I) and 30% (Group II), P = .07. A decrease in growth was detected in Group I compared with Group II (change in weight: Group I--47 g/week, Group II--85.5 g/week, P = .06; change in head circumference: Group I--0.75 cm/week, Group II--1 cm/week, P = .05).

CONCLUSION

Use of corticosteroids in very low birth weight infants dependent on mechanical ventilation during the first 10 to 14 days of life did not affect the respiratory evolution and occurrence of bronchopulmonary dysplasia, but the velocity of growth was reduced.

Effect of topical treatment with skin barrier-enhancing emollients on nosocomial infections in preterm infants in Bangladesh: a randomised controlled trial

BACKGROUND

Infections and complications of prematurity are main causes of neonatal mortality. Very low birthweight premature infants have compromised skin barrier function, and are at especially high risk for serious infections and mortality. Our aim was to ascertain whether topical application of emollients to enhance skin barrier function would prevent nosocomial infections in this population.

METHODS

We randomly assigned infants born before week 33 of gestation after admission to Dhaka Shishu Hospital, Bangladesh, to daily massage with sunflower seed oil (n=159) or Aquaphor (petrolatum, mineral oil, mineral wax, lanolin alcohol; n=157). We then compared incidence of nosocomial infections among infants in these two groups with an untreated control group (n=181) by an intention-to-treat analysis.

FINDINGS

20 patients in the control group, and 22 in each of the treatment groups left the hospital early, but were included in the final analysis. Overall, infants treated with sunflower seed oil were 41% less likely to develop nosocomial infections than controls (adjusted incidence rate ratio [IRR] 0.59, 95% CI 0.37-0.96, p=0.032). Aquaphor did not significantly reduce the risk of infection (0.60, 0.35-1.03, p=0.065). No adverse events were seen.

INTERPRETATION

Our findings confirm that skin application of sunflower seed oil provides protection against nosocomial infections in preterm very low birthweight infants. The low cost, availability, simplicity, and effect of treatment make it an important intervention for very low birthweight infants admitted to hospital in developing countries.

Histologic chorioamnionitis: an occult marker of severe pulmonary hypertension in the term newborn

OBJECTIVE

To determine whether the presence of histologic chorioamnionitis is associated with the severity of Persistent Pulmonary Hypertension of the Newborn (PPHN) as evidenced by the use of exogenous nitric oxide (iNO), high-frequency oscillatory ventilation (HFOV), extra-corporeal membrane oxygenation (ECMO) and/or death.

METHODS

Retrospective chart review of term neonates > or =37 weeks gestation with PPHN. Placental pathology was reviewed. Primary outcome is the use of iNO. Secondary outcomes include the use of HFOV, ECMO and death.

RESULTS

Over 2 years, 29 neonates fulfilled the entry criteria for the study. Interventions included iNO use n=14 (48%), HFOV n=7 (24%) and ECMO n=3 (10%); two neonates died. Histologic chorioamnionitis and/or funisitis was noted in 16 (55%) neonates. The presence of chorioamnionitis and/or funisitis (n=16) versus neither (n=13) was significantly associated with iNO use 11/16 (78%) versus 3/13 (22%) (p=0.02) and HFOV 7/16 (43%) versus 0/13 (0%) (p=0.008) but not to ECMO or death.

CONCLUSION

The presence of histologic chorioamnionitis and/or funisitis is associated with more severe PPHN as indicated by the use of iNO as well as an increased requirement for more advanced respiratory support, that is, HFOV. The mechanism/s contributing to these findings are unclear.

Gastric emptying in premature newborns with acute respiratory distress

OBJECTIVES

The authors hypothesized that acute respiratory distress (ARD) delays gastric emptying. The objective was to test this hypothesis by assessing gastric emptying on the second and seventh days of life in premature infants with ARD resulting from pulmonary disease.

METHODS

Thirty-nine newborns with ARD starting on the first day of life were selected and paired with 39 healthy control newborns matched by weight (within 250 g). Gestational age was <or =35 weeks and birth weight was < or =1750 g for all subjects. Gastric emptying was assessed at 48.0 +/- 24.0 hours and at 168.0 +/- 24.0 hours of life. A test meal consisting of 3 mL/kg of 5% glucose in water labeled with phenol red was administered by gastric tube over 1 minute and gastric retention was determined as percent test meal remaining in the stomach 30 minutes after administration.

RESULTS

Gastric retention at 30 minutes varied considerably in both groups and was significantly higher (P < 0.01) in newborns with ARD (61.4%) than controls (51.8%) at 48.0 +/- 24.0 hours, decreasing significantly after partial or full remission of ARD at 168 +/- 24 hours of life. Gastric retention was 60.2% in newborns with feeding intolerance and 36.8% in tolerant newborns (P < 0.001) at 168 hours. ARD and periventricular or intraventricular hemorrhage were predictors of gastric retention at 48 +/- 24 hours of life, whereas feeding intolerance and gestational age were predictors of gastric retention at 168 +/- 24 hours. Gastric retention was inversely correlated with gestational age.

CONCLUSION

Gastric emptying is delayed in premature infants with ARD during the first 72 hours of life and may impair the initiation of enteral feeding.

Fetal growth velocities in Hong Kong Chinese infants

Few studies have investigated the velocities of fetal growth. The aim of the present study was to determine the pattern of 'fetal' growth velocities in a Chinese population. The gestation-specific measurements of the body weight, body length and head circumference in a representative sample of 5,045 male and 4,484 female newborns delivered between 26 and 42 weeks of gestation at 12 hospitals in Hong Kong were obtained. Peak growth velocity occurred before 30 weeks of gestation for head circumference, at week 30 for length and at week 30 for weight. When compared with data obtained from a French population, a significant difference in the growth velocity for body weight was observed below 32 weeks between French and Chinese infants, suggesting an ethnic difference in fetal growth of this parameter.

Risk factors and mechanisms of preterm delivery in Malawi

PROBLEM

We examined risk factors and mechanisms of preterm delivery (PTD) in malaria-exposed pregnant women in Blantyre, Malawi.

METHOD OF STUDY

The human immunodeficiency virus (HIV), malaria, syphilis, and anemia were assessed in a cross-sectional study of 572 pregnant women. In a nested case-control study, chorioamnionitis (CAM) was examined; tumor necrosis factor (TNF)-alpha, interleukin (IL)-6, IL-8, macrophage inflammatory protein (MIP)-1alpha, monocyte chemotactic protein (MCP)-1, transforming growth factor (TGF)-beta, cortisol, and corticotropin-releasing hormone were measured in placental, maternal and/or cord blood.

RESULTS

HIV, infrequent antenatal clinic attendance, low-maternal weight, no intermittent preventive malaria therapy (IPT), and CAM were associated with PTD, while malaria was not. Of the 18 compartmental cytokine measurements, elevations in placental and/or cord IL-6 and IL-8 were associated with both CAM and PTD. In contrast, there was no overlap between the cytokines affected by malaria and those associated with PTD.

CONCLUSIONS

The HIV and CAM were the major infections associated with PTD in this study. CAM, but not malaria, causes PTD via its effect on proinflammatory cytokines.

Stable Microbubble Test on Tracheal Aspirate for the Diagnosis of Respiratory Distress Syndrome

BACKGROUND

Exogenous surfactant should be used as early as possible in the presence of respiratory distress syndrome (RDS), but diagnosis may only become clear late in the course of the disease. The stable microbubble test (SMT) in the tracheal aspirates could help in the decision to give early surfactant to preterm babies with respiratory distress.

OBJECTIVES

The objective of this study was to evaluate the accuracy of the SMT on tracheal aspirate for the diagnosis of RDS in newborns requiring mechanical ventilation.

METHODS

The test was performed on specimens obtained from 74 infants requiring mechanical ventilation, through routine suctioning.

RESULTS

Patients with RDS and meconium aspiration syndrome (MAS) had a significantly lower stable microbubble count than non-RDS and non-MAS patients. Preterm infants without RDS had a significantly higher microbubble count than preterm babies with RDS and a similar count to that of term babies. Considering a cutoff point of 120 microbubbles/mm(2) for the diagnosis of RDS, the sensitivity of the microbubble test was 96.3% (95% CI: 79.1-99.8) and the specificity 97.6% (95% CI: 85.9-99.9).

CONCLUSIONS

The SMT on tracheal aspirates is accurate for RDS diagnosis and may be useful to support the decision to give surfactant to newborns on mechanical ventilation.

Cocaine Exposure Is Associated With Subtle Compromises of Infants' and Mothers' Social-Emotional Behavior and Dyadic Features of Their Interaction in the Face-to-Face Still-Face Paradigm

Prenatal cocaine and opiate exposure are thought to subtly compromise social and emotional development. The authors observed a large sample of 236 cocaine-exposed and 459 nonexposed infants (49 were opiate exposed and 646 nonexposed) with their mothers in the face-to-face still-face paradigm. Infant and maternal behaviors were microanalytically coded. No opiate-exposure effects were detected. However, mothers of cocaine-exposed infants showed more negative engagement than other mothers. The cocaine-exposed dyads also showed higher overall levels of mismatched engagement states than other dyads, including more negative engagement when the infants were in states of neutral engagement. Infants exposed to heavier levels of cocaine showed more passive-withdrawn negative engagement and engaged in more negative affective matching with their mothers than other infants. Although effect sizes were small, cocaine exposure, especially heavy cocaine exposure, was associated with subtly negative interchanges, which may have a cumulative impact on infants' later development and their relationships with their mothers.

The low dose synacthen test: experience in well preterm infants

A pilot study to establish what constitutes a normal response to the low dose synacthen test (using 500 ng/1.73 m2 of ACTH) in well preterm infants was carried out on seven well preterm infants. Previous studies on preterm neonates (using a dose of ACTH of 36 microg/kg) suggest that a normal adrenal response is a peak serum cortisol level of > or =360 nmol/l(24). The minimum peak serum cortisol achieved by our cohort was 358 nmol/l with 6/7 infants achieving more than 360 nmol/l. 71% attained a serum cortisol increment from basal level of > or =200 nmol/l. This pilot study suggests that the criterion used to denote a normal adrenal response in preterm neonates using a dose of 36 microg/kg of ACTH (which is a peak serum cortisol of > or =360 nmol/l) can also be a applied when a physiological dose of ACTH (as used in the low dose synacthen test) is used.

Randomized, controlled trial of slow versus rapid feeding volume advancement in preterm infants

OBJECTIVES

To determine whether infants who are fed initially and advanced at 30 mL/kg per day (intervention) take fewer days to get to full feedings than those who are fed initially and advanced at 20 mL/kg per day (control), without increasing their incidence of feeding complications and necrotizing enterocolitis (NEC). We also examined whether these infants regain birth weight earlier, have fewer days of intravenous fluids, and a have shorter hospital stay.

METHODS

A randomized, controlled, single-center trial was conducted in a Neonatal Intensive Care Unit of a community-based county hospital in Houston, Texas. Infants between 1000 and 2000 g at birth, gestational age < or =35 weeks, and weight appropriate for gestational age were allocated randomly to feedings of expressed human milk or Enfamil formula starting and advanced at either 30 mL/kg per day or 20 mL/kg per day. Infants remained in the study until discharge or development of stage > or =IIA NEC.

RESULTS

A total of 155 infants were enrolled: 72 infants in the intervention group and 83 in the control group. Infants in the intervention group achieved full-volume feedings sooner (7 vs 10 days, median), regained birth weight faster (11 vs 13 days, median), and had fewer days of intravenous fluids (6 vs 8 days, median). Three infants in the intervention group and 2 control infants developed NEC for an overall incidence of 3.2% (relative risk: 1.73; 95% confidence interval: 0.30-10.06).

CONCLUSION

Among infants between 1000 and 2000 g at birth, starting and advancing feedings at 30 mL/kg per day seems to be a safe practice and results in fewer days to reach full-volume feedings than using 20 mL/kg per day. This intervention also leads to faster weight gain and fewer days of intravenous fluids.

Early postnatal growth in preterm infants and cord blood leptin

Although circulating leptin and insulin concentration is linked to intrauterine growth, fetal development and birth weight in full-term infants, there has been no enquiry into the influence of cord blood insulin and leptin for catch-up growth in preterm infants. The study evaluated the association of cord blood leptin with growth and weight gain of 96 premature babies during 6 months (corrected age). The temporal changes of anthropometric indexes over this period were calculated by repeated random regression (PROC MIXED) using SAS. Cord blood leptin was negatively associated with the rate of change in BMI (p=0.01) and length (p<0.001), from birth until 64 postnatal weeks. Insulin was positively associated with the change rate in BMI (p=0.03); however, this disappeared when adjusted for birth weight. For the first time, the association between lower leptin levels with greater catch up growth is shown for both BMI and length among preterm children. In conclusion, leptin levels at birth, but not insulin levels, predict growth rates.

Body composition in neonates: relationship between measured and derived anthropometry with dual-energy X-ray absorptiometry measurements

This study examined the relationship between measured and derived anthropometric measurements with dual-energy X-ray absorptiometry measured lean and fat mass at 3.0 +/- 2.8 (SD) days in 120 neonates with birth weights appropriate (AGA; n=74), large (LGA; n=30); or small (SGA, n=16) for gestational age. Anthropometric measurements, including total body weight and length, and regional measurements, including circumferences of head, chest, abdomen, midarm, and midthigh and dynamic skinfold thickness (15 and 60 s) at tricep, subscapular, suprailiac, and midthigh, were performed. Derived anthropometry included muscle and fat areas, and ratios were calculated from direct measurements. The skinfold thickness measurements between 15 and 60 s were highly correlated (r=0.973-0.996, p <0.001 for all comparisons). Strong correlations existed within the four circumferences of trunk and extremities, the four skinfolds, and the ratios of weight to length and its higher powers. Weight and length accounted for >97% of the variance of lean mass in AGA and SGA infants and 46% of the variance in LGA infants and for 80, 82, and 84% of the variance of fat mass in SGA, AGA, and LGA infants, respectively, whereas midarm:head circumference ratio and arm muscle and fat areas are the most important derived anthropometry in the prediction for body composition. They independently accounted for up to 16.5 and 10.2%, respectively, of the variance in body composition depending on the state of in utero growth. Thus, total body weight and length and some selected regional and derived anthropometry accounted for the vast majority of the variance of body composition.

Isoflavones in soy infant formula: a review of evidence for endocrine and other activity in infants

Soy infant formulas are widely used, but few studies have evaluated long-term safety or examined specific forms of toxicity, such as to the endocrine or immune systems. This review focuses on newer experimental studies of the effects on estrogen activity, immune function, and thyroid economy of genistein and daidzein, two isoflavones in soy infant formula, and existing human studies of soy formula use. In order to judge the likelihood that an endpoint seen in laboratory studies might occur in soy-fed infants, we examined the doses and the resulting serum or plasma concentrations from the laboratory studies and compared them with doses and concentrations seen in soy-fed infants. We also summarized the estimates of the potency of the isoflavone compounds relative to estradiol. Given the scarcity and inconsistency of existing human data and the substantial laboratory evidence of hormonal and other activity at doses relevant to the soy-fed infant, we conclude that more clinical and epidemiological study is warranted.

Perinatal or early-postnatal cytomegalovirus infection in preterm infants under 34 weeks gestation born to CMV-seropositive mothers within a high-seroprevalence population

In a prospective study, we evaluated the frequency, correlates, and clinical significance of perinatal or early-postnatal cytomegalovirus (CMV) infection in <34-week-gestation infants (n=95) born to CMV-seropositive mothers. None had congenital CMV infection. Overall, 21 (22.1%; 95% CI=14.2-31.8) infants were found to be infected; 10 excreted CMV at <60 days, and 11 had later excretion. Blood transfusion, birth weight, and vaginal delivery were not associated factors. Receiving natural breast milk within the first 30 days (OR=4.5, P=.02) or for >30 days (OR=7.9, P <.01) was associated with infection. Only one (4.8%) of the infected infants was symptomatic. For <34-week-gestation infants, frequency of perinatal and early-postnatal CMV infection is high. Early or prolonged exposure to breast milk is an associated factor. However, most infections are asymptomatic, indicating that CMV infection in preterm infants within such a population is a serious problem infrequently.

[The influence of the supine and prone positions in the esophageal pH monitoring in very low birth weight infants]

BACKGROUND

Scarce information is available on the effects of body's positioning in the number and the duration of gastroesophageal reflux episodes in very low birth weight infants.

AIM

To evaluate the influence of prone compared to supine positions on the frequency and duration of acid gastroesophageal reflux episodes in very low birth weight infants and study the role of body position in the occurrence of exams with reflux index > or = 5% and > or = 10%.

METHODS

Sixty one prolonged esophageal pH monitoring exams were retrospectively analyzed. The difference between the prone and supine position exam duration was not longer than 3 hours. The reflux index was evaluated for the total period of the exam (reflux index total) and for each period in the two positions. The total number of reflux episodes, the number of reflux episodes > 5 minutes and the longest reflux episode were evaluated for each period in the two positions. These parameters were compared in accordance with body positioning, for each one of the three reflux index total categories: reflux index total < 5%, > or = 5% and > or = 10%. The frequencies of exams with reflux index total > or = 5% and reflux index total > or = 10% were compared for both positions.

RESULTS

The number of hours in prone (11.2 +/- 1.0) and in supine (11.2 +/- 1.1) position were not different. All the prone positions monitoring parameters were significantly lower than the supine ones, in the three reflux index total categories. In the supine position, 32.7% (20/61) and 27.8% (17/61) of the exams, which were normal in prone, became abnormal, taking into account reflux index > or = 5% and > or = 10%, respectively, obtained for each position.

CONCLUSIONS

In prone position, there is a significant decrease in number and duration of acid reflux episodes in very low birth weight infants. Supine position promotes a significant increase in the number of esophageal pH monitoring exams with reflux index > or = 5% and > or = 10%, making easier the diagnose of the gastroesophageal reflux disease.

Gestational age-specific growth parameters for infants born at US military hospitals

BACKGROUND

Military hospitals currently use gestational age-specific growth curves based on data collected in Denver, Colo, from 1948 to 1961. A number of population and environmental factors and medical practice changes may make these curves nonrepresentative.

OBJECTIVE

Determine if presently used growth curves represent norms for infants born in military hospitals and create new curves for use in military hospitals.

METHODS

Data were collected from medical records of tertiary- and primary-care military hospitals. We created growth curves created for birth weight, length, and head circumference and compared these curves at gestational ages 23-42 weeks to previously published norms and to 1998 national vital statistics. Racial and ethnic differences between groups were compared. A retrospective analysis of blood-glucose measurements for healthy term infants was performed to identify potential safety issues.

RESULTS

Significant increases in growth parameters were noted for infants born in military hospitals. Specific racial and ethnic groups within the military also had an increase when compared with these groups in the United States as a whole. Less than 1% of infants classified as large for gestational age (LGA) according by old standards but average for gestational age (AGA) according to new curves experienced hypoglycemia.

CONCLUSION

Published growth curves may not represent infants born in military hospitals. Term infants born in military hospitals as a group and in racial and ethnic subgroups are larger than term infants born in US civilian hospitals. Prospective use of curves will help to validate their long-term applicability in military and civilian nurseries.

Respiratory development in preterm infants

OBJECTIVE

This study examined the development of respiration during the preterm and early post-term periods and the effects of other biological and environmental variables, including sleep state, on this development.

STUDY DESIGN

Weekly 2-hour sleep observations and respiration recordings were obtained on 134 preterm infants from the time they were no longer critical until hospital discharge; a follow-up observation was conducted 1 to 3 months later.

RESULTS

All respiratory variables, except length of respiratory pauses in quiet sleep, decreased although the rate of this decrease slowed after term for four variables. Respiratory variables, except variability of respiratory pauses lengths and periodic respiration, differed by sleep state. Covariates, except methylxanthine treatment, had minor effects. Four variables showed hospital-related differences, but cisapride treatment helped to explain the differences in three variables.

CONCLUSIONS

Much development of respiration occurs in the early weeks after birth and reflects both neural maturation and effects of other biological and environmental factors, especially medications.

Neonatal brain magnetic resonance imaging before discharge is better than serial cranial ultrasound in predicting cerebral palsy in very low birth weight preterm infants

OBJECTIVE

To compare the value of serial cranial ultrasound (US) with a single magnetic resonance imaging (MRI) before discharge in very low birth weight preterm infants to predict cerebral palsy (CP).

METHODS

Infants who weighed <1250 g at birth and were <30 weeks' gestational age underwent conventional brain MRI at near term (36-40 weeks' postmenstrual age) using 1.5 Tesla MRI scanner. Sagittal and axial T1 and T2 fluid attenuated inversion recovery and gradient recalled echo images were obtained. Cranial US was also obtained at least twice during the first 2 weeks of life. MRI and US images were interpreted by 2 independent radiologists, who were masked to clinical outcome, and scored as follows: category 1, no abnormality; category 2, subependymal hemorrhage or mineralization; category 3, moderate to severe ventriculomegaly; category 4, focal parenchymal abnormality with or without ventriculomegaly. For the purpose of this study, 1 and 2 were categorized as "normal," and 3 and 4 were categorized as "abnormal." The infants were assessed at a mean age of 20 and 31 months using the Amiel-Tison standardized neurodevelopmental examination.

RESULTS

The sensitivity and specificity of MRI for predicting CP were 71% and 91% at 20 month and 86% and 89% at 31 months, respectively. The sensitivity and specificity of US for predicting CP were 29% and 86% at 20 months and 43% and 82% at 31 months.

CONCLUSIONS

As a predictor of outcome for CP, MRI at near-term in very low birth weight preterm neonates is superior to US. However, both US and MRI demonstrate high specificity.

Avaliação de alguns aspectos da aquisição e desenvolvimento da linguagem de crianças nascidas pré-termo

A correção da idade para avaliação motora de nascidos pré-termo tem sido consenso, o que não ocorre em outros domínios do desenvolvimento. Este estudo comparou indicadores da aquisição e desenvolvimento da linguagem, considerando-se as idades cronológica e corrigida. Foram acompanhadas por 1 a 15 meses 20 crianças hígidas nascidas entre 28 e 36 semanas (mediana 32s), com 800g a 2380g (mediana 1590g), sendo 9 adequado para a idade gestacional (AIG) e 11 pequenas para a idade gestacional (PIG). A referência de normalidade foi o roteiro de Costa et al. (1992), que contém cinco níveis de linguagem. Quanto aos comportamentos receptivos, já considerando-se a idade cronológica, houve desempenho normal em todos os níveis, exceto no nível I (0-3 meses). Em relação à linguagem expressiva, considerando-se a idade cronológica, das 50 avaliações, 6 (12%) foram normais. Com a correção da idade, em 16 avaliações (40%) as crianças adequaram-se ao nível esperado, sendo mais freqüente a adequação aos 6 e 12 meses. Considerando-se a idade cronológica, houve maior número de AIG com desempenho normal (p<0,05). Com o uso da metodologia de Costa, não foi necessário corrigir a idade para avaliação da linguagem receptiva e, para a expressiva, a freqüência maior de resultados normais nas idades corrigidas para 6 e 12 meses sugere intensificação de vigilância nestas idades.

[Anthropometric cranial measures of normal newborn]

OBJECTIVE

The study has been carried out through anthropometric measures of Bahian newborns, to define measures according with the reality of this region.

METHOD

Study type transversal cut in term babies with the measures of cephalic perimeter, biauricular and anteroposterior distances, fontanel and cephalic index.

RESULTS

388 babies, 204 (52.6%) of males and 184 (47.4%) females had been evaluated. The cephalic perimeter varied between 31.0 and 38.0 cm, with 34.4 +/- 1.2 average. The cephalic index varied between 0.75 and 1.06, with 0.91 +/- 0.05 average.

CONCLUSION

The anthropometric measures are surveyed aiming at precocious detention of anomalies. Possibly, these measures can be influenced by racial factors; however, the measures carried through in Brazil follow values of foreign authors. Thus, the study shows data of a Northeastern region and points out the importance of the accomplishment of multicentric studies.

Plasma Ionized Magnesium Levelsin Neonatal Respir atory Distress Syndrome

Measurement of ionized magnesium (IMg) provides an accurate assessment of the free form of Mg, which is the physiologically active form and is most reflective of the biologically active and not easily measurable intracellular Mg fraction. Plasma levels of IMg were measured by ion-selective electrode method in premature newborns with respiratory distress syndrome (RDS), and relationships and correlations between IMg levels and various demographic, prognostic and laboratory characteristics were investigated by comparing the premature newborns with (study group; n = 19) and without RDS (control group; n = 20) in the present study. The values of the postnatal arterial pH and base excess and plasma IMg levels were significantly different between the study and control groups, and the number of newborns with any morbidity was significantly higher in the study group. Within the study group there were significant negative correlations between the plasma IMg levels and the values of the umbilical cord arterial pH (r = -0.621, p = 0.005) and base excess (r = -0.746, p = 0.001), and the value of the postnatal arterial base excess (r = -0.585, p = 0.008). The newborns who died later had higher plasma IMg levels than those who survived (0.89 +/- 0.45 vs. 0.63 +/- 0.24 mmol/l, p = 0.026). These findings suggest that increase of plasma IMg may be due to extracellular movement of Mg, which is a principally intracellular ion, as a result of acidosis, hypoxia and probable cellular injury during the early course of RDS. The exact pathophysiological mechanism responsible for IMg increase, and whether determination of plasma IMg level, including umbilical cord blood IMg measurement, can be used as an early or predictive indicator of RDS in the diagnosis remain to be determined in further large-scale studies.

Topically applied sunflower seed oil prevents invasive bacterial infections in preterm infants in Egypt: a randomized, controlled clinical trial

BACKGROUND

Because the therapeutic options for managing infections in neonates in developing countries are often limited, innovative approaches to preventing infections are needed. Topical therapy with skin barrier-enhancing products may be an effective strategy for improving neonatal outcomes, particularly among preterm, low birth weight infants whose skin barrier is temporarily but critically compromised as a result of immaturity.

METHODS

We tested the impact of topical application of sunflower seed oil 3 times daily to preterm infants <34 weeks gestational age at the Kasr El-Aini neonatal intensive care unit at Cairo University on skin condition, rates of nosocomial infections and mortality.

RESULTS

Treatment with sunflower seed oil (n = 51) resulted in a significant improvement in skin condition (P = 0.037) and a highly significant reduction in the incidence of nosocomial infections (adjusted incidence ratio, 0.46; 95% confidence interval, 0.26-0.81; P = 0.007) compared with infants not receiving topical prophylaxis (n = 52). There were no reported adverse events as a result of topical therapy.

CONCLUSIONS

Given the low cost (approximately .20 dollars for a course of therapy) and technologic simplicity of the intervention and the effect size observed in this study, a clinical trial with increased numbers of subjects is indicated to evaluate the potential of topical therapy to reduce infections and save newborn lives in developing countries.

Women's experiences using a nipple shield

An informal, retrospective telephone survey of 202 breastfeeding women was conducted over an 8-month period of time, assessing patients' perceptions regarding use of a silicone nipple shield. Women used the shield most frequently because of flat nipples (62%). Other reasons for shield use included the infant's disorganized suck (43%), sore nipples (23%), engorgement (15%), prematurity (12%), short frenulum (1%), and other reasons (1%). Forty-six percent of the women gave more than 1 reason for using a shield. Sixty-seven percent of the women continued to breastfeed after transitioning off the nipple shield. Median duration of nipple shield use for this group of women was 2 weeks. Thirty-three percent of the women who used the nipple shield with every breastfeeding breastfed from 1 day to 15 months. Five percent of women used the shield on only one side from 1 day to 9 months.

Polymorphism of tumor necrosis factor-alpha and risk and severity of bronchopulmonary dysplasia among very low birth weight infants

BACKGROUND

Preterm infants with bronchopulmonary dysplasia (BPD) exhibit prolonged elevation of inflammatory indices in their tracheal aspirates. Tumor necrosis factor-alpha (TNF-alpha) is a central mediator of the inflammatory response. The adenine-containing alleles of TNF-alpha-308 and lymphotoxin-alpha+250 have been associated with increased levels of TNF-alpha, whereas the adenine allele of TNF-alpha-238 produces lower levels of TNF-alpha after stimulation. High levels of TNF-alpha may promote chronic inflammation by overwhelming counter-regulatory mechanisms and may lead to the development of BPD. Low levels of TNF-alpha may decrease the risk and/or severity of BPD.

OBJECTIVE

To determine whether alleles of TNF-alpha play a role in the susceptibility and/or severity of BPD among very low birth weight infants.

METHODS

Infants with birth weights of < or =1250 g were included. Genotypic analyses (polymerase chain reaction-restriction fragment length polymorphism assays) were performed with DNA extracted from whole-blood samples.

RESULTS

Infants who developed BPD (fraction of inspired oxygen at postconceptional age of 36 weeks of >0.21, n = 51) had a younger gestational age (mean +/- SD: 27 +/- 4 vs 29 +/- 2 weeks) and lower birth weight (853 +/- 184 vs 997 +/- 193 g) than did infants without BPD (n = 69). The genotypic distributions of lymphotoxin-alpha+250 and TNF-alpha-308 were comparable among the groups of infants. However, the AA and GA TNF-alpha-238 genotypes were much less likely to occur among infants with BPD than among infants without BPD. The adenine allele of TNF-alpha-238 was absent among infants with severe BPD and occurred significantly less often among infants with moderate or severe BPD, compared with infants with mild BPD. The number of adenine alleles of TNF-alpha-238 was correlated inversely with the severity of BPD (r = -.341).

CONCLUSION

The adenine allele of TNF-alpha-238 may reduce the risk and severity of BPD.

Oxidative stress in term small for gestational age neonates born to undernourished mothers: a case control study

BACKGROUND

The objective of this study was to assess the status of oxidative stress in term small for gestational age (SGA) newborn infants born to undernourished mothers by estimating levels of erythrocyte superoxide dismutase (SOD), catalase, reduced glutathione, and serum malondialdehyde (MDA) in cord blood and comparing them to healthy appropriate for gestational age (AGA) controls. This was done in a case control design at a tertiary level teaching hospital.

METHODS

We included 20 singleton healthy SGA newborn infants born between 38-40 weeks to undernourished mothers with a) post-pregnancy weight < 50 kg or height < 145 cm AND b) hemoglobin < 8.0 g/dL or serum albumin < 2.5 g/dL. An equal number of age and sex matched AGA newborn infants born to healthy mothers served as Controls. Mothers with other risk factors and newborns with complications during delivery or immediate newborn period were excluded. MDA, SOD, catalase and reduced glutathione were measured in the cord blood of all neonates and compared between the groups (unpaired t test); levels were also correlated to maternal weight, height, hemoglobin, and albumin by both univariate (pearsonian correlation) and multivariate (multiple regression) analysis.

RESULTS

The activity of MDA was increased (5.33 +/- 0.72 vs 2.55 +/- 0.22 nmol/mL; P < 0.0001) while levels of superoxide dismutase (493.6 +/- 54.9 vs. 786.8 +/- 79.1 U/g Hb; P < 0.0001), catalase (1.48 +/- 0.24 vs. 2.31 +/- 0.20 U/g Hb; P < 0.0001) and reduced glutathione (2.84 +/- 0.37 vs 6.42 +/- 0.23 Umol/g Hb, P < 0.0001) were decreased in term SGA born to undernourished mothers as compared to term AGA born to healthy mothers. On univariate analysis, all the markers of oxidative stress correlated significantly with maternal parameters (P < 0.005). On multivariate analysis, maternal albumin and hemoglobin accounted for maximum correlation with the markers of oxidative stress.

CONCLUSIONS

Intrauterine malnutrition is associated with significant oxidative stress in small for gestational age neonates born at term to malnourished mothers.

The efficacy of facilitated tucking for relieving procedural pain of endotracheal suctioning in very low birthweight infants

PURPOSE

This study compared the efficacy of a behavioral pain reducing intervention (facilitated tucking) with standard neonatal intensive care unit (NICU) care for decreasing procedural pain (endotracheal suctioning) in very low birthweight (VLBW) infants.

STUDY DESIGN AND METHODS

A prospective randomized crossover design with infants as their own controls were used. The sample consisted of 40 VLBW infants, 23-32 weeks gestation, and weighing 560-1498 g with tracheal intubation. The infants were observed twice during each endotracheal suctioning experience; one suctioning was done according to normal nursery routine; another was done using facilitated tucking (the caregiver "hand-swaddling" the infant by placing a hand on the infant's head and feet while providing flexion and containment). The Premature Infant Pain Profile (PIPP) measured the infant's pain response, and severity of illness of each infant was measured by the Score for Neonatal Acute Physiology (SNAP) and the NTISS (Neonatal Therapeutic Intervention Scoring System). Repeated measures analysis of variance (RMANOVA) determined the efficacy of facilitated tucking for reducing procedural pain (PIPP) and the effects of order of intervention vs. control. Regression analyses examined the relationship of gestational age, severity of illness, and number of painful procedures to the pain response.

RESULTS

There was a significant difference between the PIPP scores for tucking and nontucking positions (p = 0.001) and a nonsignificant interaction with order (p = 0.64) as well as a nonsignificant main effect for order (p = 0.46). In the regression analyses, all predictors taken together did not significantly predict PIPP scores in the tucked position (p = 0.11) or nontucked position (p = 0.57).

CLINICAL IMPLICATIONS

Facilitated tucking is a developmentally sensitive, nonpharmacological comfort measure that can relieve procedural pain in VLBW infants. Nurses need to be increasingly aware of infant pain during daily care taking, and to use validated pain assessment instruments. Further clinical research on individual pain assessment is needed for better understanding of the quality and significance of pain for each infant, and the factors that affect pain expression.

Comparisons of mortality and pre-discharge respiratory outcomes in small-for-gestational-age and appropriate-for-gestational-age premature infants

Background

There are differences in the literature regarding outcomes of premature small-for-gestational-age (SGA) and appropriate-for gestational-age (AGA) infants, possibly due to failure to take into account gestational age at birth.

Objective

To compare mortality and respiratory morbidity of SGA and AGA premature newborn infants.

Design/Methods

A retrospective study was done of the 2,487 infants born without congenital anomalies at ≤36 weeks of gestation and admitted to the neonatal intensive care unit (NICU) at John Dempsey Hospital, between Jan. 1992 and Dec. 1999. Recent (1994–96) U.S. birth weight percentiles for gestational age (GA), race and gender were used to classify neonates as SGA (<10th percentile for GA) or AGA (10^th–90th percentile for GA). Using multivariate logistic regression and survival analyses to control for GA, SGA and AGA infants were compared for mortality and respiratory morbidity.

Results

Controlling for GA, premature SGA infants were at a higher risk for mortality (Odds ratio 3.1, P = 0.001) and at lower risk of respiratory distress syndrome (OR = 0.71, p = 0.02) than AGA infants. However multivariate logistic regression modeling found that the odds of having respiratory distress syndrome (RDS) varied between SGA and AGA infants by GA. There was no change in RDS risk in SGA infants at GA ≤ 32 wk (OR = 1.27, 95% CI 0.32 – 1.98) but significantly decreased risk for RDS at GA > 32 wk (OR = 0.41, 95% CI 0.27 – 0.63; p < 0.01). After controlling for GA, SGA infants were observed to be at a significantly higher risk for developing chronic lung disease as compared to AGA infants (OR = 2.2, 95% CI = 1.2 – 3.9, P = 0.01). There was no significant difference between SGA and AGA infants in total days on ventilator. Among infants who survived, mean length of hospital stay was significantly higher in SGA infants born between 26–36 wks GA than AGA infants.

Conclusions

Premature SGA infants have significantly higher mortality, significantly higher risk of developing chronic lung disease and longer hospital stay as compared to premature AGA infants. Even the reduced risk of RDS in infants born at ≥32 wk GA, (conferred possibly by intra-uterine stress leading to accelerated lung maturation) appears to be of transient effect and is counterbalanced by adverse effects of poor intrauterine growth on long term pulmonary outcomes such as chronic lung disease.

The maternal lifestyle study: cognitive, motor, and behavioral outcomes of cocaine-exposed and opiate-exposed infants through three years of age

OBJECTIVE

To evaluate the direct effects of prenatal cocaine exposure and prenatal opiate exposure on infant mental, motor, and behavioral outcomes longitudinally between 1 and 3 years old.

METHODS

As part of a prospective, longitudinal, multisite study, the Bayley Scales of Infant Development II were administered to 1227 infants who were exposed to cocaine (n = 474), opiates (n = 50), cocaine and opiates (n = 48), and neither substance (n = 655) at 1, 2, and 3 years of corrected age by certified, masked examiners. Hierarchic linear modeling of the 1-, 2-, and 3-year scores was conducted using cocaine and opiate exposure as predictors with and without controlling for covariates.

RESULTS

Overall retention was 88.4% and did not differ by cocaine or opiate exposure. Overall (at 1, 2, and 3 years), cocaine-exposed infants scored 1.6 Mental Development Index points below infants who were not exposed to cocaine. Opiate-exposed infants scored 3.8 Psychomotor Development Index points below infants who were not exposed to opiates. Neither the cocaine nor the opiate effect remained significant after controlling for covariates. Neither cocaine nor opiate exposure was associated with the Behavioral Record Score during the examination. Low birth weight and indices of nonoptimal caregiving were associated with lower Mental Development Index, Psychomotor Development Index, and Behavioral Record Score scores for all groups of infants.

CONCLUSIONS

In the largest at-risk sample observed longitudinally to date, infant prenatal exposure to cocaine and to opiates was not associated with mental, motor, or behavioral deficits after controlling for birth weight and environmental risks.

Aplicação do escore CRIB como preditor de óbito em unidade de terapia intensiva neonatal: uma abordagem ampliada

OBJETIVOS: avaliar o uso do escore CRIB (Clinical Risk Index for Babies) em todos os recém-nascidos internados em Unidade de Terapia Intensiva Neonatal (UTIN) e comparar seus resultados com peso ao nascer e idade gestacional. MÉTODOS: estudo observacional, envolvendo todos os recém-nascidos internados na UTIN do Hospital Universitário de Taubaté. As variáveis foram escore CRIB, peso ao nascer, idade gestacional, uso de surfactante, cateterização umbilical, asfixia neonatal e óbito. Foram comparadas as médias do escore CRIB, peso ao nascer e idade gestacional segundo óbito. Foram estimados os valores da sensibilidade, especificidade, valores preditivos positivo e negativo e risco relativo e criadas curvas Receiver Operating Characteristic (ROC) para CRIB, peso ao nascer e idade gestacional. Utilizou-se da técnica t de Student e qui-quadrado de tendência linear. A significância estatística foi alfa = 5%. RESULTADOS: óbito esteve associado a maiores valores do CRIB; houve tendência de mais casos com asfixia, uso de surfactante, cateterização umbilical e óbitos com as classes maiores do CRIB. A curva ROC relativa ao CRIB foi maior que as relativas ao peso ao nascer e idade gestacional. CONCLUSÕES: o escore CRIB foi bom preditor do óbito quando aplicado em todos os RN.

Thyroid function in seventy-five healthy preterm infants thirty to thirty-five weeks of gestational age: a prospective and longitudinal study during the first year of life

Thyroid function was evaluated in 75 healthy preterm infants, 30-35 weeks of gestational age. Serum thyrotropin (TSH), thyroxine (T(4)), triiodothyronine (T(3)), free T(4) (immunochemoluminescence) and reverse triiodothyronine (rT(3)) (radioimmunoassay) were measured in the mother and in the cord at delivery and in the preterm infants at 1 hour, 24 hours, 1 week, 3 weeks, 2 months, 4 months, 6 months, and 12 months of postnatal age. These values were compared to those of healthy full-term infants of the same postnatal age (22 at 24 hours from our hospital and from previously reported data at others times). Mean 24-hour TSH values were significantly lower (p < 0.001) in preterm than in full-term infant populations (12.38 +/- 6.13 microIU/mL versus 22.02 +/- 13.28 microIU/mL); however, all TSH values of preterm infants were in the range of the full-term values. Mean 24-hour free T(4) values were similar in preterm and full-term infants (1.88 +/- 0.46 ng/dL versus 2.01 +/- 0.54 ng/dL) and all preterm infants had free T(4) values within the range of those of full-term infants at 24 hours. Mean T(4) and T(3) values were significantly lower in preterm than in full-term neonates at 1 hour and 24 hours of age. Mean 24-hour rT(3) values were significantly higher in preterm than in full-term newborns. From 1 week onwards, all thyroid function values were in the same range in both populations. In conclusion, individual thyroid function was similar in healthy preterms and full-terms from the first 24 hours of life. Normative data in preterm infants during the first year of life applying the latest luminescence techniques currently used worldwide are reported.

Fetal adaptation to stress. Part I: acceleration of fetal maturation and earlier birth triggered by placental insufficiency in humans

This review is an attempt to provide an integrative view for the biological changes triggered by fetal stress through a multidisciplinary approach. Acceleration of brain and lung maturation in certain risk pregnancies was first described clinically and confirmed by biochemical, electrophysiological and experimental data. Moreover, new experimental findings suggest that a fetal clock centrally mediated by fetal nutritional status could determine timing of parturition. However, some skepticism persisted about the usefulness of this body of knowledge for obstetrical management in developed countries. The interest concerning this adaptation to intrauterine stress was later renewed from various sources, as developed in Part II.

Developmental patterns of physiological response to a multisensory intervention in extremely premature and high-risk infants

OBJECTIVE

To compare the developmental patterns of heart rate (HR), respiratory rate (RR), and hemoglobin oxygen saturation (SaO2) of premature infants with and without central nervous system (CNS) injury, and evaluate whether a multisensory intervention altered this development.

SAMPLE

Thirty-seven premature infants born at 23-26 weeks with normal head ultrasounds or at 24-32 weeks and diagnosed with periventricular leukomalacia (PVL) and/or intraventricular hemorrhage (IVH) were studied at 33-35 weeks postconceptional age.

DESIGN

Infants were randomly assigned to control and experimental groups. The experimental group infants received auditory, tactile, visual, and vestibular (ATVV) multisensory intervention twice daily from 33 weeks postconceptional age (PCA) until hospital discharge.

MAIN OUTCOME MEASURES

HR, RR, and SaO2 were continuously monitored during baseline, intervention, and the 30-minute postintervention period.

RESULTS

Between 33 and 35 weeks PCA, control group infants with and without CNS injury and experimental group infants without CNS injury had a significant decrease in resting mean HR, whereas RR and SaO2 remained stable. The infants with PVL who received the intervention showed increases in HR even at rest.

CONCLUSIONS

The absence of a weekly decline in HR for experimental group infants with PVL suggests that PVL may affect maturation of the autonomic nervous system and increase risk of decelerative HR changes and associated clinical compromise. Infants diagnosed with PVL should be closely monitored during procedures or interventions that may be stressful or involve handling. Further research is needed to tailor multisensory interventions for infants with PVL.

Are complete blood cell counts useful in the evaluation of asymptomatic neonates exposed to suspected chorioamnionitis?

OBJECTIVE

Chorioamnionitis complicates 1% to 10% of pregnancies and increases the risk of neonatal infection. Women with chorioamnionitis receive intrapartum antibiotics, often resulting in inconclusive neonatal blood cultures. Peripheral neutrophil values are used frequently to assist in the diagnosis of neonatal infection and to determine duration of antibiotics; we sought to determine the utility of this approach.

METHODS

A prospective observational study was performed in 856 near-term/term neonates who were exposed to suspected chorioamnionitis. Each received antibiotics for 48 hours unless clinical infection or positive blood cultures occurred. Peripheral neutrophils were measured serially and analyzed using the reference ranges of Manroe et al; an additional analysis of only the initial neutrophil values used the normal ranges of Schelonka et al. Results of neutrophil analyses were not used to determine duration of therapy. Fifty percent of asymptomatic neonates were seen postdischarge to ascertain recurrent infection. Local patient charges were examined.

RESULTS

Ninety-six percent of neonates were asymptomatic and had negative cultures, and antibiotics were discontinued at 48 hours. A total of 2427 neutrophil counts were analyzed. Although abnormal neutrophil values were more frequent in infected or symptomatic neonates, 99% of asymptomatic neonates had > or = 1 abnormal value. The specificity and negative predictive values for abnormal neutrophil values ranged between 0.12 and 0.95 and 0.91 and 0.97, respectively; sensitivity was 0.27 to 0.76. Significant differences in interpretation of the initial neutrophil values were noted, depending on the normal values used. Follow-up was performed for 373 asymptomatic neonates until 3 weeks' postnatal age. Eight required rehospitalization; none had evidence of bacterial infection. If neutrophil values had been used to determine duration of antibiotics, then local costs would have increased by 76,000 dollars to 425,000 dollars per year.

CONCLUSIONS

Single or serial neutrophil values do not assist in the diagnosis of early-onset infection or determination of duration of antibiotic therapy in asymptomatic, culture-negative neonates who are > or = 35 weeks' gestation and are delivered of women with suspected chorioamnionitis.

Physical activity combined with massage improves bone mineralization in premature infants: a randomized trial

BACKGROUND

Osteopenia of prematurity is a known source for morbidity in preterm infants. Premature infants have shown favorable outcomes in response to massage and physical activity. Whether such intervention can stimulate bone formation or decrease bone resorption is yet to be determined.

OBJECTIVE

To test the hypothesis that massage combined with physical activity can stimulate bone formation and ameliorate bone resorption in premature infants.

DESIGN/METHODS

A prospective double-blinded randomized trial was conducted at the Neonatal Intensive Care Unit of Ain Shams University in Cairo, Egypt. Thirty preterm infants (28 to 35 weeks' gestation) were randomly assigned to either control group (Group I, n=15) or intervention group (Group II, n=15). Infants in the intervention group received a daily protocol of combined massage and physical activity. Serum type I collagen C-terminal propeptide (PICP) and urinary pyridinoline crosslinks of collagen (Pyd) were used as indices for bone formation and resorption, respectively. PICP and Pyd were measured at enrollment and at discharge for all subjects. t-Test, ANOVA and linear regression analysis were used for statistical analyses.

RESULTS

There was no difference between groups I and II in gestational age (32.1+/-1.8 vs 31.5+/-1.4 weeks) or birth weight (1.429+/-0.148 vs 1.467+/-0.132 g). In the control group, serum PICP decreased over time from 82.3+/-8.5 to 68.78+/-14.6 (p<0.01), while urinary Pyd increased from 447.7+/-282.8 to 744.9+/-373.6 (p<0.01) indicating decreased bone formation and increased bone resorption, respectively. In the intervention group, serum PICP increased over time from 62.5+/-13.8 to 73.84+/-12.9 (p<0.01). Urinary Pyd also increased over time from 445.7+/-266.5 to 716.8+/-301.8 (p<0.01). In a linear regression model including gestational age and intervention, serum PICP increased significantly in the intervention group (regression coefficient 18.8+/-4.6, p=0.0001) while urinary Pyd did not differ between groups (regression coefficient=5.6+/-114.3, p=0.961).

CONCLUSIONS

A combined massage and physical activity protocol improved bone formation (PICP) but did not affect bone resorption (Pyd). Pyd increased over time in both groups, possibly due to continuous bone resorption and Ca mobilization.

Low blood pressure among very-low-birth-weight infants with fetal vessel inflammation

OBJECTIVE

To test the hypothesis that fetal vessel inflammation (FVI: funisitis and/or fetal vasculitis) is associated with lower blood pressure (BP) over the first week of life and an increased risk of periventricular leukomalacia (PVL) among premature infants.

STUDY DESIGN

A total of 255 infants born at <1350 g to normotensive mothers were stratified by gestational age (GA) and grouped by presence/absence of FVI on placental pathology. Daily highest (Hi) and lowest (Lo) systolic BP (BP(sys)), mean BP (BP(mn)) and diastolic BP (BP(dia)) over first 7 days of life were analyzed by repeated measures ANOVA and regression analysis. Cranial ultrasounds were obtained at 2 weeks of life.

RESULTS

Infants > or =30 weeks gestation with FVI had lower HiBP(sys), HiBP(mn), HiBP(dia), LoBP(sys), LoBP(mn) and LoBP(dia) (p<0.001) than did infants without FVI. Infants with PVL (all < or =27 weeks gestation) had lower LoBP(mn) and LoBP(dia) (p<0.01) than controls. FVI did not increase the risk of PVL in these infants.

CONCLUSION

FVI and PVL are associated with reduced BP over the first week of life.

Incidence, course, and prediction of hyperbilirubinemia in near-term and term newborns

OBJECTIVE

In this study, we investigated prospectively the incidence of significant hyperbilirubinemia and demographic and laboratory characteristics and pattern of serum bilirubin levels of near-term newborns (35-37 weeks' [245-265 days'] gestation) by comparing them with those of term newborns (38-42 weeks' [266-294 days'] gestation) longitudinally in the first 7 days of life; we also aimed to determine the value of an early (6th-hour) serum bilirubin measurement in predicting the development of significant hyperbilirubinemia later during the first week of life in near-term newborns.

METHODS

Serum total bilirubin measurements were initially made at the 6th hour of life and repeated daily for the next 4 days, and a last measurement was performed on the 7th day (150th hour) in 219 term newborns (term group) and 146 near-term newborns (near-term group). Newborns with serum total bilirubin levels of > or =8 and > or =12 mg/dL on day 2, > or =12 and > or 15 mg/dL on day 3, and > or =14 and > or =17 mg/dL on days 4, 5, and 7 for birth weights 2000 to 2500 g and >2500 g, respectively, were defined to have significant hyperbilirubinemia, and phototherapy treatment was started. The predictive ability of the 6th-hour serum total bilirubin value in determining the development of significant hyperbilirubinemia in the near-term group was assessed on the basis of the placement of any of the first week's serum bilirubin measurements in the > or =95th percentile of the study population. A Gaussian distribution curve, the 5th, 30th, 60th, and 95th percentiles, and 4 percentile tracks were obtained from mean serum total bilirubin values. On the basis of the percentile tracks with various sensitivity, specificity, and negative and positive predictive values, a nomogram demonstrating the 4 percentile tracks as risk-zone demarcators with divided risk zones was produced.

RESULTS

Twenty-three newborns (10.5%) in the term group and 37 newborns (25.3%) in the near-term group had significant hyperbilirubinemia and required phototherapy. When the daily mean serum bilirubin levels of the 2 groups were compared, the first 4 days' values did not significantly differ between the 2 groups, whereas the 5th and 7th days' values were significantly higher in the near-term group. There were significant differences between the 2 groups with respect to the incidence of significant hyperbilirubinemia, hematocrit, Apgar score, and mode of delivery. On the age-specific nomogram, the zone >95th percentile was labeled as high risk, and that <5th percentile was labeled as low risk. Serum total bilirubin values between the 5th and 30th, 30th and 60th, and 60th and 95th percentiles were designated as being in the low-intermediate, intermediate, and high-intermediate risk zones, respectively. The 5th and 95th percentiles on the nomogram had the highest sensitivity (100%) and specificity (98.2%), respectively, in predicting the subsequent development of significant hyperbilirubinemia.

CONCLUSIONS

Near-term newborns should not be treated as term newborns in the approach to management of hyperbilirubinemia, because infants of 35 to 37 weeks' gestation had significantly lower birth weights, significantly higher serum total bilirubin levels on days 5 and 7, and were 2.4 times more likely to develop significant hyperbilirubinemia than those of 38 to 42 weeks' gestation in the present study. In near-term newborns of 35 to 37 weeks' (245 to 265 days') gestation, the decision to diagnose and treat significant hyperbilirubinemia should be made on the basis of risk status (percentile distribution of the serum bilirubin values on postnatal age) rather than using birth-weight-based thresholds. A nomogram constructed from daily serum bilirubin values of each population, as we present herein, can be used in assessing the age (hour)-specific jaundice risk (high, intermediate, or low) of each near-term newborn.