Outcome for infants at high risk of major handicap

McCarthy Performance and Neurological Functioning in Children Born "At Risk"

The neurophysiological paradigm is increasing in popularity in education and psychology, although the complexity of behavior-to-brain inference may limit its immediate utility. The present study examines the relationship of three neurological measures and their relationship to the McCarthy Scales of Children's Abilities from a concurrent-and predictive-validity perspective. Also investigated is the ability of traditional neurocognitive McCarthy indicators to differentiate between children with and without signs of neurologic abnormality. Findings warrant a dual approach to neuropsychological assessment (clinical and quantitated) and also sugest that the McCarthy Motor Scale may be of value in assessing the neurologic integrity in the 4-year-old. Findings concerning traditional neurocognitive indicators are inconclusive.

Neonatal intensive care and the prevention of major handicap

During the past 20 years there has been a great increase in the understanding of deranged physiological mechanisms in certain groups of newborn infants that were, in the past, at high risk for death or major handicap. Much information of direct clinical relevance has come from the study of experimental animals, particularly about the changes that occur in the lungs and circulation at birth. Work in progress on an animal model of intraventricular haemorrhage suggests that this, like many other causes of brain damage, is a potentially preventable condition. Technological advances, such as continuous blood-gas analysis, make the prevention of handicapping conditions simpler, but the application of modern methods can be expensive. Current evidence shows that neonatal intensive care saves lives, and that the incidence of major handicap in the survivors is reduced. Society will have to decide how much money should be put into this area of medicine, and it will also have to help neonatal paediatricians with the difficult ethical dilemmas that they are now having to face.

Inadequacy of FDA dosing guidelines for theophylline use in neonates

The efficacy of the FDA guidelines for theophylline dosing in newborns was evaluated retrospectively in 224 patients who had clearance data available. Mean projected post loading dose serum concentration was 4.1 +/- 1.0 mg/L in 160 patients. Mean projected steady-state concentration was 4.8 +/- 1.6 mg/L in 189 patients receiving intravenous aminophylline and 4.2 +/- 1.3 mg/L in 35 patients on oral therapy. Projected serum concentrations were subtherapeutic (less than 6.0 mg/L) in 181 of the 224 patients analyzed. There was a statistically significant difference in serum concentrations between asphyxiated and nonasphyxiated patients (p less than 0.001). There was no significant difference in mean projected serum concentrations between patients age 26-41 weeks (postconceptional age). This study suggests that the FDA dosing guidelines for theophylline in infants is inadequate and results in subtherapeutic (less than 6.0 mg/L) serum concentrations in the majority of newborns.

Ultrasound appearance of the brain in very preterm infants and neurodevelopmental outcome at 18 months of age

The brains of 158 consecutively admitted very preterm infants were repeatedly examined with real time ultrasound. Abnormalities, most commonly periventricular haemorrhage, were detected in 79 (50%). The 109 infants who survived were followed up until they were 16-23 months old. Major or minor neurological or developmental sequelae were found in 5 of 62 infants (8%) with normal ultrasound scans and in an identical proportion, 2 of 25 infants (8%), with uncomplicated periventricular haemorrhage. By contrast, 15 of 21 infants (71%) whose ventricles became enlarged (with or without periventricular haemorrhage) had abnormalities at follow up. The proportion with sequelae depended on the cause and extent of the enlargement. Three of 8 infants (38%) with mild (usually transient) ventricular distension had sequelae, compared with 3 of 4 (75%) with hydrocephalus and 9 of 9 (100%) with cerebral atrophy (2 of whom also had hydrocephalus). Adverse neurodevelopmental sequelae at follow up appeared more often to be attributable to cerebral ischaemia and infarction than to periventricular haemorrhage.

Very low birth weight children at school age: comparison of neonatal management methods

The outcome of 293 infants born to a geographically defined community and weighing 501-1500 g was investigated. Medical intervention in the newborn period had been avoided. Morbidity was assessed at school age. Of the infants, 236 had been live born in the labour ward of this hospital; of these, 117 (49.6%) died in the neonatal period, one (0.4%) died in the first year, four (1.7%) were untraced, 13 (5.5%) had major handicap, 29 (12.3%) had minor handicap, and 72 (30.5%) were considered to be normal. In terms of survival, handicap, and intellectual with that of infants born over the same period (1963-71) in areas where intensive methods of perinatal care were used. These results imply that postnatal survival and potential of infants of very low birth weight are by no means prejudiced when only experienced nursing care is available.

24-hour tape recordings of ECG and respiration in the newborn infant with findings related to sudden death and unexplained brain damage in infancy

A system for simultaneous 24-hour tape recording of ECG and respiration has been developed and used in the study of 4 groups of newborn infants. In 50 randomly selected, healthy term infants, the mean lowest heart rate (>9 beats' duration; was 88 ± 13. 14 (28%) infants had junctional escape rhythms, 5 had supraventricular, and 2 ventricular premature beats. 34 (68%) subjects had apnoeic episodes ≥10 seconds' duration; the 95th centile for maximum duration of apnoea was 18 seconds, the longest episode being 28 seconds. Episodes of bradycardia <100/minute were associated with 50 of a total of 288 episodes of apnoea of 10-14 seconds, with all 4 episodes of 15-19 seconds, and with both episodes ≥20 seconds. In 100 randomly selected, healthy, preterm or low birthweight infants studied within 5 days of their discharge from hospital, the mean lowest heart rate was 91 ± 18. 18 had junctional, one idioventricular, and 3 both junctional and idioventricular escape rhythms. Two had supraventricular and 6 had ventricular premature beats. 66 subjects had apnoeic episodes ≥10 seconds' duration; the 95th centile for maximum duration of apnoea was 20 seconds, the longest episode being 52 seconds. Episodes of bradycardia <100/min were associated with 84 of a total of 608 episodes of apnoea 10-14 seconds' duration, with 21 of 37 episodes of 15-19 seconds, and with 15 of 15≥20 seconds. One preterm infant with a maximum apnoeic episode of 52 seconds had an associated bradycardia of 27/min. Three of 5 `near-miss' cot death infants and one preterm infant with a family history of cot death studied immediately before discharge showed prolonged apnoea >40 seconds, or extreme bradycardia <50/min, or both. Finally, 11 infants with arrhythmias on a standard ECG were studied. Of these, 6 with premature beats and 3 of 5 with episodes of bradycardia did not exhibit apnoea during arrhythmias. Two of the 5 babies with bradycardia however, demonstrated associated apnoea of 10-14 seconds. There may be a relationship between latent episodes of prolonged apnoea and bradycardia and hypoxaemic brain damage or sudden infant death.