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Shepherd E, Mcintyre S, Smithers-Sheedy H, Ashwood P, Sullivan TR, Te Velde A, Doyle LW, Makrides M, Middleton P, Crowther CA. Linking data from a large clinical trial with the Australian Cerebral Palsy Register. Dev Med Child Neurol 2020; 62:1170-1175. [PMID: 32383806 DOI: 10.1111/dmcn.14556] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/01/2020] [Indexed: 11/27/2022]
Abstract
AIM To link data from a large maternal perinatal trial with the Australian Cerebral Palsy Register (ACPR) to identify children with cerebral palsy (CP). METHOD Deidentified data from the Australasian Collaborative Trial of Magnesium Sulphate (ACTOMgSO4 ) and the ACPR were linked. Children born from 1996 to 2000 at Australian hospitals who survived and had 2-year paediatric assessments were included. Children identified with CP in: (1) both the ACTOMgSO4 (2y) and the ACPR (5y), (2) the ACTOMgSO4 only, and (3) the ACPR only were compared. RESULTS We included 913 children (492 males, 421 females; mean gestational age at birth 27.8wks [standard deviation 2.1wks]; range 23.0-40.0wks). Eighty-four children received a CP diagnosis: 35 by the ACTOMgSO4 and the ACPR, 29 by the ACTOMgSO4 only, and 20 by the ACPR only. The ACTOMgSO4 diagnosed 76.2% (95% confidence interval [CI] 65.9-84.1) and the ACPR identified 65.5% (95% CI 54.7-74.9). Children born in states/territories with long-standing versus more recently established registers were more likely to be included on the ACPR (p<0.05). INTERPRETATION Linking deidentified perinatal trial data with the ACPR was achieved. Limitations of both strategies for identifying children with CP in this era (late 1990s and early 2000s) probably explain many of the differences observed, and inform future linkage studies and evaluations of CP-preventive interventions. WHAT THIS PAPER ADDS Randomized trial data were linked with the Australian Cerebral Palsy Register. Trial (2y) and register (up to 5y) diagnoses of cerebral palsy (CP) differed. States with long-standing registers were more likely to include children with CP.
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Affiliation(s)
- Emily Shepherd
- SA Health and Medical Research Institute, Adelaide, SA, Australia.,Discipline of Obstetrics and Gynaecology, Adelaide Medical School, The University of Adelaide, Adelaide, SA, Australia
| | - Sarah Mcintyre
- Cerebral Palsy Alliance, Discipline of Child and Adolescent Health, The University of Sydney, Sydney, NSW, Australia.,Discipline of Child and Adolescent Health, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Hayley Smithers-Sheedy
- Cerebral Palsy Alliance, Discipline of Child and Adolescent Health, The University of Sydney, Sydney, NSW, Australia.,Discipline of Child and Adolescent Health, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Pat Ashwood
- Discipline of Obstetrics and Gynaecology, Adelaide Medical School, The University of Adelaide, Adelaide, SA, Australia
| | - Thomas R Sullivan
- SA Health and Medical Research Institute, Adelaide, SA, Australia.,School of Public Health, The University of Adelaide, Adelaide, SA, Australia
| | - Anna Te Velde
- Cerebral Palsy Alliance, Discipline of Child and Adolescent Health, The University of Sydney, Sydney, NSW, Australia.,Discipline of Child and Adolescent Health, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Lex W Doyle
- Victorian Infant Brain Studies, The Murdoch Children's Research Institute, Melbourne, Vic, Australia.,Neonatal Services, Royal Women's Hospital, Melbourne, Vic, Australia.,Department of Obstetrics and Gynaecology, The University of Melbourne, Melbourne, Vic, Australia.,Department of Paediatrics, The University of Melbourne, Melbourne, Vic, Australia
| | - Maria Makrides
- SA Health and Medical Research Institute, Adelaide, SA, Australia.,Discipline of Paediatrics, Adelaide Medical School, The University of Adelaide, Adelaide, SA, Australia
| | - Philippa Middleton
- SA Health and Medical Research Institute, Adelaide, SA, Australia.,Discipline of Obstetrics and Gynaecology, Adelaide Medical School, The University of Adelaide, Adelaide, SA, Australia
| | - Caroline A Crowther
- Discipline of Obstetrics and Gynaecology, Adelaide Medical School, The University of Adelaide, Adelaide, SA, Australia.,Liggins Institute, The University of Auckland, Auckland, New Zealand
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Cartwright RD, Crowther CA, Anderson PJ, Harding JE, Doyle LW, McKinlay CJD. Association of Fetal Growth Restriction With Neurocognitive Function After Repeated Antenatal Betamethasone Treatment vs Placebo: Secondary Analysis of the ACTORDS Randomized Clinical Trial. JAMA Netw Open 2019; 2:e187636. [PMID: 30707225 PMCID: PMC6484607 DOI: 10.1001/jamanetworkopen.2018.7636] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2018] [Accepted: 12/10/2018] [Indexed: 11/24/2022] Open
Abstract
Importance Repeated doses of antenatal betamethasone are recommended for women at less than 32 weeks' gestation with ongoing risk of preterm birth. However, concern that this therapy may be associated with adverse neurocognitive effects in children with fetal growth restriction (FGR) remains. Objective To determine the influence of FGR on the effects of repeated doses of antenatal betamethasone on neurocognitive function in midchildhood. Design, Setting, and Participants This preplanned secondary analysis of data from the multicenter Australasian Collaborative Trial of Repeat Doses of Corticosteroids (ACTORDS) included women at less than 32 weeks' gestation with ongoing risk of preterm birth (<32 weeks) at least 7 days after an initial course of antenatal corticosteroids who were treated at 23 hospitals across Australia and New Zealand from April 1, 1998, through July 20, 2004. Participants were randomized to intramuscular betamethasone or saline placebo; treatment could be repeated weekly if the woman was judged to be at continued risk of preterm birth. All surviving children were invited to a midchildhood outcome study. Data for this study were collected from October 27, 2006, through March 18, 2011, and analyzed from June 1 through 30, 2018. Interventions At 6 to 8 years of corrected age, children were assessed by a pediatrician and psychologist for neurosensory and cognitive function, and parents completed standardized questionnaires. Main Outcomes and Measures The prespecified primary outcomes were survival free of any disability and death or survival with moderate to severe disability. Results Of 1059 eligible children, 988 (55.0% male; mean [SD] age at follow-up, 7.5 [1.1] years) were assessed at midchildhood. The FGR rate was 139 of 493 children (28.2%) in the repeated betamethasone treatment group and 122 of 495 (24.6%) in the placebo group (P = .20). Primary outcome rates were similar between treatment groups for the FGR and non-FGR subgroups, with no evidence of an interaction effect for survival free of any disability (FGR group, 108 of 144 [75.0%] for repeated betamethasone treatment vs 91 of 126 [72.2%] for placebo groups [odds ratio [OR], 1.1; 95% CI, 0.6-1.9]; non-FGR group, 267 of 335 [79.7%] for repeated betamethasone vs 283 of 358 [79.0%] for placebo groups [OR, 1.0; 95% CI, 0.7-1.5]; P = .77) and death or moderate to severe disability (FGR group, 21 of 144 [14.6%] for repeated betamethasone treatment vs 20 of 126 [15.9%] for placebo groups [OR, 0.9; 95% CI, 0.4-1.9]; non-FGR group, 29 of 335 [8.6%] for repeated betamethasone vs 36 of 358 [10.0%] for placebo [OR, 0.8; 95% CI, 0.4-1.3]; P = .84). Conclusions and Relevance In this study, repeated antenatal betamethasone treatment compared with placebo was not associated with adverse effects on neurocognitive function at 6 to 8 years of age, even in the presence of FGR. Physicians should use repeated doses of antenatal corticosteroids when indicated before preterm birth, regardless of FGR, in view of the associated neonatal benefits and absence of later adverse effects. Trial Registration anzctr.org.au Identifier: ACTRN12606000318583.
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Affiliation(s)
| | - Caroline A. Crowther
- Liggins Institute, University of Auckland, Auckland, New Zealand
- Discipline of Obstetrics and Gynaecology, School of Medicine, University of Adelaide, Adelaide, Australia
| | - Peter J. Anderson
- Monash Institute of Cognitive and Clinical Neurosciences, Monash University, Melbourne, Australia
- Clinical Sciences, Murdoch Children’s Research Institute, Parkville, Australia
| | - Jane E. Harding
- Liggins Institute, University of Auckland, Auckland, New Zealand
| | - Lex W. Doyle
- Clinical Sciences, Murdoch Children’s Research Institute, Parkville, Australia
- Department of Paediatrics, University of Melbourne, Parkville, Australia
- Department of Obstetrics and Gynaecology, The Royal Women’s Hospital, University of Melbourne, Parkville, Australia
| | - Christopher J. D. McKinlay
- Liggins Institute, University of Auckland, Auckland, New Zealand
- Department of Paediatrics: Child and Youth Health, University of Auckland, Auckland, New Zealand
- Kidz First Neonatal Care, Counties Manukau Health, Auckland, New Zealand
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3
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Crowther CA, Anderson PJ, McKinlay CJD, Harding JE, Ashwood PJ, Haslam RR, Robinson JS, Doyle LW. Mid-Childhood Outcomes of Repeat Antenatal Corticosteroids: A Randomized Controlled Trial. Pediatrics 2016; 138:peds.2016-0947. [PMID: 27650051 DOI: 10.1542/peds.2016-0947] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/15/2016] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE To assess if exposure to repeat dose(s) of antenatal corticosteroids has beneficial effects on neurodevelopment and general health in mid-childhood, at 6 to 8 years' corrected age. METHODS Women at risk for very preterm birth, who had received a course of corticosteroids ≥7 days previously, were randomized to intramuscular betamethasone (11.4 mg Celestone Chronodose) or saline placebo, repeated weekly if risk of very preterm birth remained. Mid-childhood assessments included neurocognitive function, behavior, growth, lung function, blood pressure, health-related quality of life, and health service utilization. The primary outcome was survival free of neurosensory disability. RESULTS Of the 1059 eligible long-term survivors, 963 (91%) were included in the primary outcome; 479 (91%) in the repeat corticosteroid group and 484 (91%) in the placebo group. The rate of survival free of neurosensory disability was similar in both groups (78.3% repeat versus 77.3% placebo; risk ratio 1.00, 95% confidence interval, 0.94-1.08). Neurodevelopment, including cognitive function, and behavior, body size, blood pressure, spirometry, and health-related quality of life were similar in both groups, as was the use of health services. CONCLUSIONS Treatment with repeat dose(s) of antenatal corticosteroids was associated with neither benefit nor harm in mid-childhood. Our finding of long-term safety supports the use of repeat dose(s) of antenatal corticosteroids, in view of the related neonatal benefits. For women at risk for preterm birth before 32 weeks' gestation, ≥7 days after an initial course of antenatal corticosteroids, clinicians could consider using a single injection of betamethasone, repeated weekly if risk remains.
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Affiliation(s)
- Caroline A Crowther
- Liggins Institute, University of Auckland, Auckland, New Zealand; .,Discipline of Obstetrics and Gynaecology, School of Medicine, The University of Adelaide, Adelaide, Australia
| | - Peter J Anderson
- Clinical Sciences, Murdoch Children's Research Institute, Parkville, Victoria, Australia.,Department of Paediatrics, University of Melbourne, Parkville, Victoria, Australia
| | | | - Jane E Harding
- Liggins Institute, University of Auckland, Auckland, New Zealand
| | - Pat J Ashwood
- Discipline of Obstetrics and Gynaecology, School of Medicine, The University of Adelaide, Adelaide, Australia
| | - Ross R Haslam
- The Women's and Children's Hospital, Adelaide, South Australia, Australia; and
| | - Jeffery S Robinson
- Discipline of Obstetrics and Gynaecology, School of Medicine, The University of Adelaide, Adelaide, Australia
| | - Lex W Doyle
- Clinical Sciences, Murdoch Children's Research Institute, Parkville, Victoria, Australia.,Department of Paediatrics, University of Melbourne, Parkville, Victoria, Australia.,Department of Obstetrics and Gynaecology, The Royal Women's Hospital, University of Melbourne, Parkville, Victoria, Australia
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Sinha S, Tin W. Adjunctive drug therapies for treatment of respiratory diseases in the newborn: based on evidence or habit? Ther Adv Respir Dis 2014; 8:53-62. [PMID: 24670391 DOI: 10.1177/1753465814526444] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Respiratory distress syndrome is a disease of prematurity and is caused by a relative deficiency of endogenous surfactant production. Respiratory distress syndrome is the most common cause of mortality and morbidity in the newborn population and the standard of care is to provide exogenous surfactant therapy. This saves lives and reduces respiratory complications but, despite treatment, a significant proportion of these infants go onto develop chronic lung disease, the severest form of which is bronchopulmonary dysplasia. Once developed, this is a multisystem disease and treatment is mostly supportive by using various therapeutic adjuncts. Some of these have been proven to be safe and effective in large randomized, controlled trials but similar evidence for other drugs is lacking. The aim of this paper is to provide an overview and critically appraise the available scientific evidence for or against their use in routine practice.
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Affiliation(s)
- Sunil Sinha
- University of Durham & The James Cook University Hospital, Department of Neonatal Medicine, Marton Road, Middlesbrough TS4 3BW, UK
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Abstract
Bronchopulmonary dysplasia (BPD), also known as chronic lung disease (CLD), is one of the most challenging complications in premature infants. The incidence of BPD has been increasing over the past two decades in parallel with an improvement in the survival of this population. Furthermore, the clinical characteristics and the natural history of infants affected by BPD have changed considerably, and newer definitions to clarify the term 'BPD' have also evolved since its first description more than four decades ago. Several drug therapies have also evolved, either to manage these infants' respiratory distress syndrome with an aim to prevent BPD or to manage the established condition. Although there is good evidence to support the 'routine' use of some therapies, many other therapies currently used in relation to BPD remain individual- or institution-specific, depending on beliefs and myths that we have adopted. In this article, we discuss the importance of defining BPD more objectively and the support--or lack thereof--for the drug therapies used in relation to BPD.
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Affiliation(s)
- Win Tin
- James Cook University Hospital, Marton Road, Middlesbrough, UK
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6
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Xiong X, Saunders LD, Wang FL, Davidge ST, Buekens P. Preeclampsia and Cerebral Palsy in Low-Birth-Weight and Preterm Infants: Implications for the Current “Ischemic Model” of Preeclampsia. Hypertens Pregnancy 2009. [DOI: 10.3109/10641950109152637] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Al-Saif S, Alvaro R, Manfreda J, Kwiatkowski K, Cates D, Qurashi M, Rigatto H. A randomized controlled trial of theophylline versus CO2 inhalation for treating apnea of prematurity. J Pediatr 2008; 153:513-8. [PMID: 18534618 DOI: 10.1016/j.jpeds.2008.04.025] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2007] [Revised: 02/06/2008] [Accepted: 04/07/2008] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To determine whether inhalation of 0.8% CO(2) in preterm infants decreases the duration and rate of apnea as effectively as or better than theophylline with fewer adverse side effects. STUDY DESIGN A prospective, randomized, control study of 42 preterm infants of gestational age 27 to 32 weeks assigned to receive inhaled CO(2) (n = 21) or theophylline (n = 21). The study group had a mean (+/- standard error of the mean) birth weight of 1437 +/- 57 g, gestational age of 29.4 +/- 0.3 weeks, and postnatal age of 43 +/- 4 days. After a control period, 0.8% CO(2) or theophylline was given for 2 hours, followed by a recovery period. RESULTS In the CO(2) group, apneic time and rate decreased significantly, from 9.4 +/- 1.6 seconds/minute and 94 +/- 15 apneic episodes/hour to 3.0 +/- 0.5 seconds/minute and 34 +/- 5 apneic episodes/hour. In the theophylline group, apneic time and rate decreased significantly, from 8 +/- 1 seconds/minute and 80 +/- 8 apneic episodes/hour to 2.5 +/- 0.4 seconds/minute and 28 +/- 3 apneic episodes/hour. Cerebral blood flow velocity (CBFV) decreased only during theophylline administration. CONCLUSIONS Our findings suggest that inhaled low (0.8%) CO(2) concentrations in preterm infants is at least as effective as theophylline in decreasing the duration and number of apneic episodes, has fewer side effects, and causes no changes in CBFV. We speculate that CO(2) may be a better treatment for apnea of prematurity than methylxanthines.
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Affiliation(s)
- Saif Al-Saif
- Department of Pediatrics, University of Manitoba, Winnipeg, Manitoba, Canada
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8
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Crowther CA, Doyle LW, Haslam RR, Hiller JE, Harding JE, Robinson JS. Outcomes at 2 years of age after repeat doses of antenatal corticosteroids. N Engl J Med 2007; 357:1179-89. [PMID: 17881750 DOI: 10.1056/nejmoa071152] [Citation(s) in RCA: 186] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND We previously reported the results of a randomized, controlled trial showing that repeat doses of antenatal corticosteroids reduced the risk of respiratory distress syndrome and serious neonatal morbidity. However, data have not been available regarding longer-term effects of this treatment. METHODS Women who had received an initial course of corticosteroid treatment 7 or more days previously were randomly assigned to receive an intramuscular injection of corticosteroid (11.4 mg of betamethasone) or saline placebo; the dose was repeated weekly if the mother was still considered to be at risk for preterm delivery and the duration of gestation was less than 32 weeks. We assessed survival free of major neurosensory disability and body size of the children at 2 years of corrected age. RESULTS Of the 1085 children who were alive at 2 years of age, 1047 (96.5%) were seen for assessment (521 exposed to repeat-corticosteroid treatment and 526 exposed to placebo). The rate of survival free of major disability was similar in the repeat-corticosteroid and placebo groups (84.4% and 81.0%, respectively; adjusted relative risk, 1.04, 95% confidence interval, 0.98 to 1.10; adjusted P=0.20). There were no significant differences between the groups in body size, blood pressure, use of health services, respiratory morbidity, or child behavior scores, although children exposed to repeat doses of corticosteroids were more likely than those exposed to placebo to warrant assessment for attention problems (P=0.04). CONCLUSIONS Administration of repeat doses of antenatal corticosteroids reduces neonatal morbidity without changing either survival free of major neurosensory disability or body size at 2 years of age. (Current Controlled Trials number, ISRCTN48656428 [controlled-trials.com].).
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Affiliation(s)
- Caroline A Crowther
- Disciplines of Obstetrics and Gynaecology, University of Adelaide, Women's and Children's Hospital, Adelaide, Australia.
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Ross S. Composite outcomes in randomized clinical trials: arguments for and against. Am J Obstet Gynecol 2007; 196:119.e1-6. [PMID: 17306647 DOI: 10.1016/j.ajog.2006.10.903] [Citation(s) in RCA: 61] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2006] [Revised: 08/09/2006] [Accepted: 10/25/2006] [Indexed: 11/18/2022]
Abstract
Composite outcomes that combine a number of individual outcomes (such as types of morbidity) are frequently used as primary outcomes in obstetrical trials. The main argument for their use is to ensure that trials can answer important clinical questions in a timely fashion, without needing huge sample sizes. Arguments against their use are that composite outcomes may be difficult to use and interpret, leading to errors in sample size estimation, possible contradictory trial results, and difficulty in interpreting findings. Such problems may reduce the credibility of the research, and may impact on the implementation of findings. Composite outcomes are an attractive solution to help to overcome the problem of limited available resources for clinical trials. However, future studies should carefully consider both the advantages and disadvantages before using composite outcomes. Rigorous development and reporting of composite outcomes is essential if the research is to be useful.
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Affiliation(s)
- Sue Ross
- Department of Obstetrics and Gynaecology, University of Calgary, Calgary, Alberta, Canada
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Hunt CE, Corwin MJ, Baird T, Tinsley LR, Palmer P, Ramanathan R, Crowell DH, Schafer S, Martin RJ, Hufford D, Peucker M, Weese-Mayer DE, Silvestri JM, Neuman MR, Cantey-Kiser J. Cardiorespiratory events detected by home memory monitoring and one-year neurodevelopmental outcome. J Pediatr 2004; 145:465-71. [PMID: 15480368 DOI: 10.1016/j.jpeds.2004.05.045] [Citation(s) in RCA: 54] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To determine if infants with cardiorespiratory events detected by home memory monitoring during early infancy have decreased neurodevelopmental performance. STUDY DESIGN Infants (n = 256) enrolled in the Collaborative Home Infant Monitoring Evaluation also completed the Bayley Scales of Infant Development II at 92 weeks' postconceptional age. Infants were classified as having 0, 1 to 4, or 5+ cardiorespiratory events. Events were defined as apnea >or=20 seconds or heart rate <60 to 80 bpm or <50 to 60 bpm, for >or=5 to 15 seconds, depending on age. RESULTS For term infants, having 0, 1 to 4, and 5+ cardiorespiratory events was associated with unadjusted mean Mental Developmental Index (MDI) values (+/-SD) of 103.6 (10.6), 104.2 (10.7), and 97.7 (10.9), respectively, and mean Psychomotor Developmental Index (PDI) values of 109.5 (16.6), 105.8 (16.5), and 100.2 (17.4). For preterm infants, having 0, 1 to 4, and 5+ cardiorespiratory events was associated with unadjusted mean MDI values of 100.4 (10.3), 96.8 (11.5), and 95.8 (10.6), respectively, and mean PDI values of 91.7 (19.2), 93.8 (15.5), and 94.4 (17.7). The adjusted difference in mean MDI scores with 5+ events compared with 0 events was 5.6 points lower in term infants ( P = .03) and 4.9 points lower in preterm infants ( P = .04). CONCLUSIONS Having 5+ conventional events is associated with lower adjusted mean differences in MDI in term and preterm infants.
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Affiliation(s)
- Carl E Hunt
- National Center on Sleep Disorders Research, National Heart, Lung, and Blood Institute, 6705 Rockledge Dr, Ste 6022, Bethesda, MD 20892-7993, USA
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11
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Nelson KB, Grether JK, Dambrosia JM, Walsh E, Kohler S, Satyanarayana G, Nelson PG, Dickens BF, Phillips TM. Neonatal cytokines and cerebral palsy in very preterm infants. Pediatr Res 2003; 53:600-7. [PMID: 12612192 DOI: 10.1203/01.pdr.0000056802.22454.ab] [Citation(s) in RCA: 125] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
To examine the relationship of cytokines in blood of very preterm neonates with later diagnosis of spastic cerebral palsy (CP) compared with infants of similar gestational age without CP, we measured concentrations of inflammatory cytokines and other substances in archived neonatal blood by recycling immunoaffinity chromatography. Subjects were surviving children born before 32 wk gestational age (GA) to women without preeclampsia, 64 with later diagnoses of CP and 107 control children. The initial analyses were augmented by measurement of 11 cytokines by a bead-based flow analytic system (Luminex) in an additional 37 children with CP and 34 control children from the same cohort. Concentrations of examined substances did not differ by presence of indicators of infection in mother, infant, or placenta. On ANOVA, concentrations of a number of cytokines were significantly related to neonatal ultrasound abnormalities (periventricular leukomalacia, ventricular enlargement, or moderate or severe germinal matrix hemorrhage). None of the substances measured either by immunoaffinity chromatography or flow analytic methods, including IL-1, -6, and -8 and tumor necrosis factor-alpha, was related to later diagnosis of CP or its subtypes. Inflammatory cytokines in neonatal blood of very premature infants did not distinguish those with later diagnoses of CP from control children.
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Affiliation(s)
- Karin B Nelson
- Neuroepidemiology Branch, National Institutes of Neurological Disorder and Stroke, Bethesda, MD 20892, USA.
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Topp M, Uldall P, Greisen G. Cerebral palsy births in eastern Denmark, 1987--90: implications for neonatal care. Paediatr Perinat Epidemiol 2001; 15:271-7. [PMID: 11489156 DOI: 10.1046/j.1365-3016.2001.00354.x] [Citation(s) in RCA: 68] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
The Cerebral Palsy Register in eastern Denmark has collected cases using a uniform data sampling procedure since birth year 1979. We have investigated changes in the rate of cerebral palsy, related to gestational age, mortality and perinatal risk factors in children born 1983--90. The total cerebral palsy birth prevalence decreased from 3.0 in the birth year period 1983--86 to 2.4 per 1000 live births (P < 0.01) in 1987--90, owing to a decrease among all preterm infants (29--19 per 1000, P < 0.001). The perinatal and early neonatal mortality in preterm infants was unchanged from 1983--86 to 1987--90. The rate of cerebral palsy in term infants was 1.5 per 1000 in all birth-year periods from 1979--90. Among the cerebral palsy infants, the proportion of very preterm babies treated with mechanical ventilation in the neonatal period decreased from 95% in 1983--86 to 61% in 1987--90 (P < 0.001), while the group treated with CPAP among the moderately preterm babies increased from 61% to 78% (P < 0.05). The significant decline in cerebral palsy rate in preterm infants born 1987--90 may be due to a change in treatment at the neonatal intensive care units using less mechanical ventilation, a hypothesis which needs further investigation.
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Affiliation(s)
- M Topp
- The Cerebral Palsy Registry in Denmark, National Institute of Public Health, Copenhagen, Denmark.
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13
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Al-Aif S, Alvaro R, Manfreda J, Kwiatkowski K, Cates D, Rigatto H. Inhalation of low (0.5%-1.5%) CO2 as a potential treatment for apnea of prematurity. Semin Perinatol 2001; 25:100-6. [PMID: 11339662 DOI: 10.1053/sper.2001.23199] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Apnea of prematurity is common and none of the treatments being used are fully effective and free of significant adverse side effects. We hypothesized that low concentrations of CO2 (< or = 1.5%) may reduce apnea without causing discomfort from an increase in ventilation. We studied 10 preterm infants at a gestational age of 32+/-1 wk (mean +/- SEM) and birthweight 1.8+/-0.2 kg. After a control period of 1 hour, concentrations of CO2 were given (0.5%, 1%, and 1.5%) for 1 hour each, followed by a recovery period of 1 hour. Apnea number significantly decreased from 2.0+/-0.3 apneas/min during control to 1.0+/-0.1 apneas/min (0.5% CO2; P < .05), 1.1+/-0.2 (1% CO2; P < .05), and to 0.7+/-0.2 (1.5% CO2; P < .01). The apnea time significantly decreased from 14.2+/-2.5 s/min during control to 5.2+/-0.8 (0.5% CO2; P < .01), 5.8+/-0.7 (1% CO2; P < .01), and to 3.7+/-0.9 (1.5% CO2; P < .01). Minute ventilation significantly increased with CO2 without evidence of respiratory discomfort. TcPCO2 did not change and TcPO2 increased slightly. These findings suggest that inhalation of low concentrations of CO2 in preterm infants with apnea 1) decreases the number and time of apneas, 2) improves oxygenation, 3) increases ventilation, and 4) is effective even in such low concentrations as 0.5%. We speculate that inhalation of CO2 (< 1%) is more effective and safer than methylxanthines for the treatment of apnea of prematurity.
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Affiliation(s)
- S Al-Aif
- Department of Pediatrics, University of Manitoba, Winnipeg, Canada
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Abstract
The balance of current evidence indicates that intrauterine exposure to infection and inflammation contributes to the risk of cerebral palsy. The mechanisms involved are not well understood and may differ in very immature versus term infants. Term infants exposed to maternal infection are predisposed to delivery room depression and neonatal encephalopathy.
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Affiliation(s)
- K B Nelson
- Neuroepidemiology Branch, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, USA.
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15
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Davis PG, Doyle LW, Rickards AL, Kelly EA, Ford GW, Davis NM, Callanan C. Methylxanthines and sensorineural outcome at 14 years in children < 1501 g birthweight. J Paediatr Child Health 2000; 36:47-50. [PMID: 10723691 DOI: 10.1046/j.1440-1754.2000.00446.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVES Methylxanthines, including theophylline, have been used extensively and successfully to treat apnoea in preterm infants. However, long-term consequences of such therapy are largely unknown. The aim of this study was to determine the relationship between theophylline therapy and outcome at 14 years of age in surviving preterm children of birthweight < 1501 g. METHODOLOGY The subjects of this study were 154 consecutive survivors with birthweights < 1501 g born from 1 October 1980 to 31 March 1982; 130 (84.4%) were assessed at 14 years of age. Outcomes included motor function, psychological test scores, and growth. RESULTS Of the 130 children assessed, 69 (53.1%) had been exposed to theophylline; 13.0% had cerebral palsy, significantly higher than 1.6% in the 61 children not exposed to theophylline (P < 0.02). This difference remained statistically significant after adjusting for potential confounding variables including the presence of cerebroventricular haemorrhage. In contrast, after adjusting for known confounding variables, children who had received theophylline achieved higher psychological test scores. There was no association between theophylline therapy and growth. CONCLUSIONS Theophylline therapy in the newborn period is associated with some evidence of harmful, but also helpful sensorineural effects at 14 years of age.
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Affiliation(s)
- P G Davis
- Department of Obstetrics and Gynaecology, University of Melbourne, Australia.
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16
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Affiliation(s)
- B Schmidt
- Departments of Pediatrics and Clinical Epidemiology & Biostatistics, McMaster University Hamilton, Ontario L8N 3Z5 Canada
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17
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Dammann O, Allred EN, Veelken N. Increased risk of spastic diplegia among very low birth weight children after preterm labor or prelabor rupture of membranes. J Pediatr 1998; 132:531-5. [PMID: 9544916 DOI: 10.1016/s0022-3476(98)70035-6] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Our objective was to study the association of spastic diplegia (SDP; N = 29) with the initiator of preterm birth in a regional cohort of 312 6-year-old very low birth weight children (< or =1500 gm). We determined the prevalence of SDP among those children born after idiopathic preterm onset of labor (POOL) or prelabor rupture of membranes (PROM) (12% SDP), and among those born after pregnancy-induced hypertension or other medical indications for preterm delivery (4% SDP). Stratification showed that 83% of the children with diplegia were born after POOL or PROM. The threefold increased risk of SDP among those children born after POOL or PROM compared with the remainder of the cohort (crude odds ratio 3.2, 95% confidence interval 1.2 to 8.5) remained elevated after controlling for perinatal and neonatal variables (odds ratio 2.4 to 2.7) in logistic regression models. We conclude that birth after POOL or PROM increases the risk of SDP among very low birth weight children and speculate that this might be related to infectious processes leading to both POOL or PROM and SDP.
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Affiliation(s)
- O Dammann
- Department of Neurology, Children's Hospital, Boston, Massachusetts 02115, USA
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18
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19
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Surgery and the tiny baby: sensorineural outcome at 5 years of age. The Victorian Infant Collaborative Study Group. J Paediatr Child Health 1996; 32:167-72. [PMID: 9156529 DOI: 10.1111/j.1440-1754.1996.tb00916.x] [Citation(s) in RCA: 52] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE To determine whether an association exists between long-term sensorineural outcome and the need for surgery requiring general anaesthesia during the primary hospitalization in extremely preterm (<27 weeks of gestational age) or extremely low birthweight (ELBW birthweight <100Og) infants. METHODOLOGY A geographically determined cohort study of extremely preterm or ELBW children in the State of Victoria, Australia. The study subjects were consecutive survivors with either gestational ages <27 weeks or birthweights <10OOg born in the State of Victoria during 3 years from 1 January 1985. The main outcome measure was the rate of sensorineural disability at 5 or more years of age in relation to surgical procedures requiring general anaesthesia performed during the primary hospitalization. RESULTS Of 221 children surviving to 5 years of age, 54 (24.4%) had at least one surgical operation requiring general anaesthesia during their primary hospitalization. The operations included the following: (i) ligation of ductus arteriosus (n = 26); (ii) inguinal hernia repair (n = 16); (iii) central nervous system surgery (n = 4); (iv) gastrointestinal surgery (n = 5); and (v) tracheostomy or bronchoscopy (n = 5). Of the 221 survivors to 5 years of age, 218 (98.6%) were assessed for sensorineural impairments and disabilities. Of the 53 children who were assessed at 5 or more years of age and who had had surgery, 7 (13.2%) were severely disabled, 8 (15.1%) were moderately disabled, 12 (22.6%) were mildly disabled,and 26 (49.1%) were non-disabled. The overall rate of sensorineural disability was significantly higher in children who had been operated on compared with those who had not (Mann-Whitney U-test, z =3.7, P<0.001). CONCLUSIONS There is an adverse association between the need for surgery requiring general anaesthesia during the primary hospitalization and sensorineural outcome in extremely preterm or ELBW infants.
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20
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Abstract
Perinatal asphyxia, whether prenatal, intrapartum, or neonatal is thought to be a significant contributor to newborn morbidity and mortality as well as long-term neurological deficits. Development of an intrapartum tool/test that can reliably identify and discriminate between varying degrees of fetal acidemia and suggest whether it is respiratory or metabolic in nature would be highly desirable. This article critically reviews the available experience with the currently available monitoring techniques and the significance of abnormalities of fetal and intrapartum measurements with respect to the predictive value of the observations available to the clinician.
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Affiliation(s)
- R Depp
- Department of Obstetrics and Gynecology, Jefferson Medical College, Philadelphia, PA 19107, USA
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21
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Abstract
I have attempted to give an overview of the latest thoughts on the aetiology of the cerebral palsies. These motor disabilities are of continuing interest and their prevalence is rising, particularly in low birth weight preterm singletons and multiple births. The likely multiplicity of causes demands intelligent investigation probably in collaborative population data bases. Ultrasound and other scans may provide better data on both site and timing of neonatal brain damage. However these are more likely to have been done on cerebral palsied children who were preterm than on those born at term. There are currently no clear preventive messages except those relating to postnatal cerebral palsy or encouraging strategies to reverse the increases in multiple births. The challenges now are to obtain better data on the antenatal factors and on causal sequences which may be important. The Little Foundation is seeking to encourage such collaborative studies. Other suggestions from our workshop [14] included attempting to follow up those infants who have been participants in large randomised controlled trials (such as those evaluating surfactant) to the age when they can be confidently diagnosed as having cerebral palsy. If antenatal data have been collected on them they may form the basis for a cohort analysis relating risk to cerebral palsy occurrence, as well as to answer questions about whether the intervention influenced cerebral palsy occurrence.
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Affiliation(s)
- F J Stanley
- Western Australian Research Institute for Child Health, Perth
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22
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Ikonen RS, Janas MO, Koivikko MJ, Laippala P, Kuusinen EJ. Hyperbilirubinemia, hypocarbia and periventricular leukomalacia in preterm infants: relationship to cerebral palsy. Acta Paediatr 1992; 81:802-7. [PMID: 1421887 DOI: 10.1111/j.1651-2227.1992.tb12107.x] [Citation(s) in RCA: 68] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
This study comprised 103 preterm infants with a gestational age less than 33 weeks who were born in Tampere University Hospital and who were followed up to two years of age. Sixty-four perinatal variables were compared to ultrasound findings in the neonatal period and neurologic handicap at the age of two years. Duration of hypocarbia (PCO2 < or = 30 mmHg) during the first 72 h and hyperbilirubinemia (the mean level of serum total bilirubin) at three days of age were independently and significantly related to periventricular leukomalacia, but not directly to cerebral palsy. The only perinatal variables related independently and significantly to cerebral palsy at two years of age were periventricular leukomalacia and ventriculomegaly. According to these results, periventricular leukomalacia was the main predictor of cerebral palsy in preterm infants. In addition to hypocarbia, hyperbilirubinemia may also be involved in the pathogenesis of extensive (severe cystic) periventricular leukomalacia.
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Affiliation(s)
- R S Ikonen
- Department of Pediatrics, Tampere University Hospital, Finland
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Stanley FJ, Watson L. Trends in perinatal mortality and cerebral palsy in Western Australia, 1967 to 1985. BMJ (CLINICAL RESEARCH ED.) 1992; 304:1658-63. [PMID: 1633518 PMCID: PMC1882364 DOI: 10.1136/bmj.304.6843.1658] [Citation(s) in RCA: 196] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
OBJECTIVE To analyse the trends in stillbirths, neonatal deaths, and cerebral palsy in all infants born in Western Australia from 1967 to 1985. To relate these trends to changes in perinatal care, particularly in relation to avoidance of intrapartum asphyxia in term infants and the increased survival of low birthweight infants. DESIGN Descriptive epidemiological study calculating population rates for perinatal deaths and cerebral palsy according to year of birth and birth weight. SETTING Western Australia. SUBJECTS All infants born after 20 weeks' gestation or weighing at least 400 g (live and stillborn). MAIN OUTCOME MEASURES Stillbirths, neonatal deaths (from perinatal death certificates), and cerebral palsy (from a population based register). RESULTS Overall stillbirth rates fell from 12.1/1000 total births in 1967-70 to 8.1 in 1983-5. Early neonatal mortality fell from 13.0/1000 live births to 4.4 over the same period whereas total cerebral palsy rates remained at around 2-2.5/1000 live births. Death rates fell in all birth weight categories, particularly in low birthweight infants between 1975 and 1985, the period when birthweight data were available. In contrast, cerebral palsy rates in infants under 1500 g rose significantly over this period (from 12.1 in 1968 to 64.9 in 1985). The rise was seen in all spastic categories, including severely and multiply handicapped children. CONCLUSIONS Large increases in the use of interventions aimed at reducing birth asphyxia and handicaps had not (by 1985) resulted in lower rates of cerebral palsy. This suggests that birth asphyxia is not a major cause. The increased survival of low birthweight infants has resulted in more cerebral palsy in this group, due either to postnatal complications of immaturity or prenatal damage to the fetal brain. These findings have implications for planning perinatal care and for litigation for putative obstetric malpractice in cerebral palsy cases.
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Affiliation(s)
- F J Stanley
- Western Australian Research Institute for Child Health, Princess Margaret Hospital for Children
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al-Rajeh S, Bademosi O, Awada A, Ismail H, al-Shammasi S, Dawodu A. Cerebral palsy in Saudi Arabia: a case-control study of risk factors. Dev Med Child Neurol 1991; 33:1048-52. [PMID: 1778341 DOI: 10.1111/j.1469-8749.1991.tb14826.x] [Citation(s) in RCA: 31] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
There is increasing evidence that cerebral palsy (CP) in developed countries results mainly from antenatal factors, whereas reports from developing countries suggest that perinatal and postnatal factors may be more important because of less than optimal delivery conditions. The authors studied 103 Saudi children with CP and compared their antecedent factors with those of a control group. The major risk factors identified were a history of CP in a sibling and consanguinity of the parents. Low birthweight (less than 2000g), gestational age less than 32 weeks, twin pregnancy and respiratory distress were significantly more frequent among CP cases than controls. The results suggest that antenatal factors, including inherited ones, play a major role in the pathogenesis of CP in Saudi Arabia, which is contrary to previous reports from this region. Their contribution to the pathogenesis of CP in developing countries may be greater than previously assumed.
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Affiliation(s)
- S al-Rajeh
- Department of Neurology, College of Medicine and Medical Sciences, King Faisal University, Dammam, Saudi Arabia
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Abstract
The influence of knowledge of their medical history on the assessment of at-risk infants was examined. Two at-risk infants, one with a high-risk medical history and one with a low-risk history, were assessed and videotaped using the Movement Assessment of Infants. 41 physical therapists were randomly assigned to assess the videotaped examinations in four groups with different knowledge of the infants' histories (high-risk infant with actual or low-risk history; low-risk infant with actual or high-risk history). The clinical significance of the difference in total risk scores between knowledge conditions of a high-risk history and a low-risk history was greater for the low-risk infant. The higher mean total risk score for the low-risk infant assessed with a high-risk history suggests that false positive results could occur which may alter parents' perceptions and interactions with the infants and consequently influence their development.
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Affiliation(s)
- B Ashton
- Physical Therapy Department, Glenrose Rehabilitation Hospital, Edmonton, Alberta, Canada
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Hagberg B, Hagberg G, Zetterstrom R. Decreasing perinatal mortality--increase in cerebral palsy morbidity. ACTA PAEDIATRICA SCANDINAVICA 1989; 78:664-70. [PMID: 2688352 DOI: 10.1111/j.1651-2227.1989.tb11123.x] [Citation(s) in RCA: 83] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Affiliation(s)
- B Hagberg
- Department of Pediatrics 11, University of Gothenburg, Sweden
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Binder H, Eng GD. Rehabilitation management of children with spastic diplegic cerebral palsy. Arch Phys Med Rehabil 1989; 70:482-9. [PMID: 2658915 DOI: 10.1016/0003-9993(89)90012-9] [Citation(s) in RCA: 23] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Spastic diplegia has been recognized as the type of cerebral palsy most frequently associated with prematurity. Due to constantly improving neonatal care in developed countries, more and smaller premature infants are surviving, and the number of spastic diplegic children can be expected to increase. This paper reviews the incidence, pathophysiology, and associated handicaps of patients with this type of cerebral palsy. The role of the physiatrist and aspects of traditional management are discussed. Recent advances in treatment of spasticity and lower extremity bracing are stressed as they seem to be particularly suitable to spastic diplegic patients.
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Affiliation(s)
- H Binder
- Department of PM&R, Children's Hospital National Medical Center, Washington, DC 20010
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Tudehope DI, Masel J, Mohay H, O'Callaghan M, Burns Y, Rogers Y, Williams G. Neonatal cranial ultrasonography as predictor of 2 year outcome of very low birthweight infants. AUSTRALIAN PAEDIATRIC JOURNAL 1989; 25:66-71. [PMID: 2472134 DOI: 10.1111/j.1440-1754.1989.tb01418.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Real time ultrasound scans using an ATL 300C sector scanner with 5-7.5 MHz transducer were performed on days 1, 4, 7 and thereafter as clinically necessary on 153 consecutively discharged very low birthweight (VLBW) infants. One hundred and forty-six long-term survivors were assessed fully at 2 years. The prevalence of cerebroventricular haemorrhage (CVH) in these survivors was 34.2% (grade 1-21.2%; grade 2-4.8%; grade 3-3.4%; grade 4-4.8%), ventricular dilatation 19.9% (including 4.1% with ventriculoperitoneal shunt), and ischaemia 9%. Impairments at 2 years were classified as nil, mild, moderate, severe or multiply severe, based on the criteria of Kitchen et al. Overall, 120 infants (82.2%) were unimpaired and 6.2% had mild, 3.4% had moderate, 4.1% had severe and 4.1% had multiply severe impairment. The major factors associated with impairment were gestational age less than 28 weeks, birthweight less than 1000 g, vaginal delivery, respiratory distress syndrome, mechanical ventilation, pulmonary air leaks and CVH. When these factors were reanalysed in a logistic regression model for odds ratios, only CVH (P less than 0.005) and birth by spontaneous vaginal delivery (P less than 0.05) were significant. The prevalence of impairment was 11.4% with no CVH, 6.5% grade 1, 71% grade 2, 20.0% grade 3 and 100.0% grade 4 CVH. The sensitivity of CVH of grade 2 or greater as a screening test was 64.7% for impairment, 78.6% for cerebral palsy and 70% for severe intellectual handicap. The mean general quotient (GQ) (Griffiths) at 2 years for infants with CVH was 89.1, and 97.5 for those without CVH (P less than 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)
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Affiliation(s)
- D I Tudehope
- Department of Neonatology, Mater Misericordiae Public Hospitals, South Brisbane, Queensland, Australia
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Affiliation(s)
- B S Russman
- University of Connecticut Medical School, Newington Children's Hospital, Connecticut
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