Childhood outcomes after low-grade intraventricular haemorrhage: A systematic review and meta-analysis

Preterm Hemorrhagic Brain Injury: Recent Advances on Evaluation and Management

Preterm infants are at risk for germinal matrix hemorrhage and intraventricular hemorrhage (GMH-IVH), which can evolve into posthemorrhagic ventricular dilatation (PHVD) and periventricular hemorrhagic infarction. In this review, we provide an overview of the pathophysiology and presentation of the patterns of preterm hemorrhagic brain injury and provide recommendations for evaluation and management. Cranial ultrasound is the preferred neuroimaging modality to screen for and monitor the progression of GMH-IVH, and optimal scanning timing is reviewed. Key strategies for management are presented and emerging therapies for PHVD management are reviewed. We conclude by discussing the neurodevelopmental outcome trajectories.

Study of Demographic Characteristics, Management Details and Early Life Outcomes of Indigenous Infants With Chronic Neonatal Lung Disease in North Queensland

OBJECTIVE

To study the demographic characteristics, risk factors, management details and clinical outcomes to 12 months corrected age in indigenous and non-indigenous infants with chronic neonatal lung disease in North Queensland.

DESIGN

Retrospective cohort study of infants with chronic neonatal lung disease admitted to a tertiary neonatal intensive care unit in regional Queensland from January 2015 to December 2019.

RESULTS

There were 139 infants with chronic neonatal lung disease and 425 controls. The incidence of chronic neonatal lung disease in infants born at < 33 weeks gestational age was 32.6% versus 20.4% in indigenous and non-indigenous infants, respectively (OR 1.8, p value 0.001). Indigenous infants had significantly lower birth weight (830 g vs. 1000 g, p value 0.039), higher rate of maternal smoking during the pregnancy (57.4% vs. 25%, p value < 0.001), were less likely to be inborn (71.4% vs. 88.2%, p value 0.017) or receive adequate course of antenatal corticosteroids (30.2% vs. 59.2%, p value < 0.001), had increased incidence of grade 2 intraventricular haemorrhage (17.5% vs. 4%, p value 0.01) and were more likely to reside in a very remote locality (17.4% vs. 3.9%, p < 0.001). Identified risk factors for chronic neonatal lung disease included lower birth weight (OR 0.99, p value 0.014), lower birth gestation (OR 1.57, p value 0.003), longer duration of continuous positive airway pressure (OR 1.004, p value < 0.001), longer duration of humidified high-flow nasal prongs (OR 1.003, p < 0.001), doses of surfactant (OR 1.55, p value 0.038) and receiving post-natal steroids (OR 19.03, p < 0.001). There were no other significant differences in comorbidities, management, complications, number of hospital admissions or weight to 12-months corrected age.

CONCLUSIONS

Indigenous infants had increased antenatal risk factors for chronic neonatal lung disease and account for a disproportionate number of cases, however, their outcomes to 12 months corrected age were similar to non-indigenous infants.

Intraventricular Hemorrhage and Survival, Multimorbidity, and Neurodevelopment

Importance

Intraventricular hemorrhage (IVH) has proven to be a challenging and enduring complication of prematurity. However, its association with neurodevelopment across the spectrum of IVH severity, independent of prematurity, and in the context of contemporary care remains uncertain.

Objective

To evaluate national trends in IVH diagnosis and the association with survival and neurodevelopmental outcomes at 2 years of age.

Design, Setting, and Participants

This whole-population cohort study was conducted using data from the UK National Neonatal Research Database. Infants born at less than 29 weeks' gestation with any grade of IVH between January 2013 and December 2019 in England were included and matched with controls. Data analysis occurred from November 2023 to June 2024.

Exposure

IVH grades 1 to 4 (Papile classification).

Main Outcomes and Measures

The primary outcome was survival without severe neurodevelopmental impairment (NDI) at 2 years' corrected age including severe delays (inability to understand or use >5 words or signs; being unable to walk, sit, or use hands; blindness; or uncorrectable hearing impairment). Secondary outcomes included gross and fine motor function, receptive and expressive communication, vision, hearing, and overall developmental progress. Outcomes were derived from clinician-entered data and analyzed using multiple logistic regression.

Results

Between 2013 and 2019, of 26 756 infants born at less 29 weeks' gestation in England, 8461 received a diagnosis of IVH (5570 low-grade and 2891 high-grade, and 8328 were included in the study. Overall, 5519 included infants had low-grade IVH with a median [IQR] gestational age of 26 (25-27) weeks, of which 2477 (48.88%) were male. Of the 2809 included infants with high-grade IVH, the median (IQR) gestational age was 25 (24-26) weeks and 1710 (60.88%) were male. The mean (SD) incidence of high-grade IVH (108 [6.7] per 1000 live extremely preterm births) and low-grade IVH (208 [10.4] per 1000 live extremely preterm births) increased between 2013 and 2019, although this did not reach statistical significance for high-grade IVH. Survival without severe NDI decreased significantly after high-grade IVH (a 74% reduction; aOR, 0.26; 95% CI, 0.22-0.31), and to a lesser extent after low-grade IVH (a 12% reduction; aOR, 0.88; 95% CI, 0.79-0.98). Although low-grade IVH was associated with functional impairments, most survivors, 2283 of 4379 infants (52.15%), had no NDI, and the association with NDI was accounted for by grade 2 IVH. Decreased survival without severe NDI was observed with increasing grade of IVH, decreasing gestation, bilateral compared to unilateral injuries, and increasing morbidity count (severe retinopathy of prematurity, bronchopulmonary dysplasia, and surgical necrotizing enterocolitis). Impairments in gross motor function and communication were common, especially among those with high-grade IVH (with prevalences of 44.55% [715 of 1605 infants] and 48.91% [784 of 1603 infants], respectively).

Conclusions and Relevance

In this cohort study, IVH was highlighted as a persistent issue with substantial neurodevelopmental implications despite advances in care. This study offers useful data for counseling families; however, follow-up to school age is necessary to grasp the full impact of these injuries on children's lives.

Early neurodevelopmental outcomes of preterm infants with intraventricular haemorrhage and periventricular leukomalacia

AIM

Intraventricular haemorrhage (IVH) and periventricular leukomalacia (PVL) in preterm infants are associated with an increased risk of long-term neurodevelopmental impairments (NDI) and cerebral palsy (CP). However, little is known about their impact on early neurodevelopmental outcomes despite increasing evidence highlighting the feasibility and importance of early NDI/CP diagnosis. We aimed to determine the early neurodevelopmental outcomes of preterm infants with IVH and PVL.

METHODS

This was a retrospective single-centre cohort study of preterm infants born at <29 weeks gestation or <1000 g birth weight who attended an Early Neurodevelopment Clinic at 3 to 4 months of corrected age. Primary outcomes of early NDI and CP/high-risk CP diagnoses based on Prechtl's General Movements Assessment and the Hammersmith Infant Neurological Examination were compared between infants without IVH and infants with mild IVH (grades I-II), severe IVH (grades III-IV), and severe brain injury (SBI; severe IVH or cystic PVL).

RESULTS

Of 313 infants, 52.1% (n = 163), 41.2% (n = 129), 6.7% (n = 21) and 8.6% (n = 27) had no IVH, mild IVH, severe IVH and SBI, respectively. The adjusted odds of early CP/high-risk CP diagnosis were significantly higher in infants with severe IVH (aOR 6.07, 95% CI 1.50-24.50) and SBI (aOR 15.28, 95% CI 3.70-63), but not in those with mild IVH (aOR 1.24, 95% CI 0.49-3.10). However, the adjusted odds of any early NDI were similar across groups.

CONCLUSION

Preterm infants with severe IVH and SBI are at increased risk of early CP/high-risk of CP diagnosis at 3 to 4 months of corrected age.

Electrical Cardiometry during transition and short-term outcome in very preterm infants: a prospective observational study

The purpose of this study is to evaluate the association of Electrical Cardiometry (EC)-derived cardiac output indexed to weight (CO) and its changes during the first 48 h in relation to adverse short-term outcome in very preterm infants. In this prospective observational study of preterm infants < 32 weeks gestational age (GA), the combined adverse outcome was defined as mortality or abnormal cranial ultrasound (any grade intracranial hemorrhage (ICH) or periventricular leukomalacia) within the first 2 weeks postnatally. Logistic regression models were used to investigate the association between median CO and outcome and mixed-effects models for the time trajectory of CO. In the absence of device-specific thresholds for low or high CO, no thresholds were used in our analysis. Fifty-three infants (median (IQR) GA 29.0 (25.4-30.6) weeks, birthweight 1020 (745-1505) g) were included in the analysis. Median CO was 241 (197-275) mL/kg/min for the adverse outcome and 198 (175-227) mL/kg/min for normal outcome (odds ratio (OR) (95% confidence interval (95% CI)), 1.01 (1.00 to 1.03); p = 0.028). After adjustment for GA, the difference was not significant (adjusted OR (95% CI), 1.01 (0.99 to 1.02); p = 0.373). CO trajectory did not differ by outcome (p = 0.352). A post hoc analysis revealed an association between CO time trajectory and ICH ≥ grade 2.          Conclusions: EC-derived CO estimates within 48 h postnatally were not independently associated with brain injury (any grade) or mortality in the first 14 days of life. CO time trajectory was found to be associated with ICH ≥ grade 2. What is Known: • Bioreactance-derived cardiac output indexed to bodyweight (CO) in the transitional period has been associated with adverse short-term outcome in preterm infants. What is New: • Electrical Cardiometry (EC)-derived CO measurements in very preterm infants during the transitional period are not independently associated with adverse outcome (death or ultrasound detected brain damage) within 2 weeks postnatally. • In the first 48 h EC-derived CO increases over time and is higher in extremely preterm infants compared to very preterm and differs from previously reported bioreactance-derived CO values.

Neuroimaging to guide neuroprognostication in the neonatal intensive care unit

PURPOSE OF REVIEW

Neurological problems are common in infants admitted to the neonatal intensive care unit (NICU). Various neuroimaging modalities are available for neonatal brain imaging and are selected based on presenting problem, timing and patient stability.

RECENT FINDINGS

Neuroimaging findings, taken together with clinical factors and serial neurological examination can be used to predict future neurodevelopmental outcomes. In this narrative review, we discuss neonatal neuroimaging modalities, and how these can be optimally utilized to assess infants in the NICU. We will review common patterns of brain injury and neurodevelopmental outcomes in hypoxic-ischemic encephalopathy, perinatal arterial ischemic stroke and preterm brain injury.

SUMMARY

Timely and accurate neuroprognostication can identify infants at risk for neurodevelopmental impairment and allow for early intervention and targeted therapies to improve outcomes.