Grade and laterality of intraventricular haemorrhage to predict 18-22 month neurodevelopmental outcomes in extremely low birthweight infants

Neurodevelopmental outcomes in preterm or low birth weight infants with germinal matrix-intraventricular hemorrhage: a meta-analysis

BACKGROUND

This meta-analysis aimed to identify the near- and long-term neurodevelopmental prognoses of preterm or low birth weight (LBW) infants with different severities of intraventricular hemorrhage (IVH).

METHODS

Four databases were searched for observational studies that were qualified using the Newcastle-Ottawa Scale.

RESULTS

37 studies involving 32,370 children were included. Compared to children without IVH, children with mild IVH had higher incidences of neurodevelopmental impairment (NDI), cerebral palsy (CP), motor/cognitive delay, hearing impairment and visual impairment, as well as lower scores of the mental development index (MDI) and psychomotor development (PDI). Moreover, compared to mild IVH, severe IVH increased susceptibilities of children to NDI, motor delay, CP, hearing impairment and visual impairment, with worse performances in MDI, PDI, motor score and IQ. Mild IVH was not associated with seizures or epilepsy.

CONCLUSIONS

Adverse neurodevelopmental outcomes positively associated with the occurrence and severity of IVH in preterm or LBW infants, providing evidence for counseling and further decisions regarding early therapeutic interventions.

IMPACT

Adverse neurodevelopmental outcomes later in life were closely associated with the occurrence and severity of IVH in preterm or LBW infants. Our results highlight the importance to make prediction of the neurodevelopmental outcomes of children born preterm or LBW with a history of IVH, which will guide affected parents when their children need clinical interventions to reach the full potential. We emphasize the importance of identifying specific developmental delays that may exist in children with IVH, providing detailed information for the development of comprehensive intervention measures.

Variations in neonatal mortality of preterm infants with intraparenchymal haemorrhage in Europe: the EPICE cohort

OBJECTIVE

The aim of this study was to investigate variations in mortality before neonatal intensive care unit (NICU) discharge of infants born preterm with intraparenchymal haemorrhage (IPH) in Europe with a special interest for withdrawing life-sustaining therapy (WLST).

DESIGN

Secondary analysis of the Effective Perinatal Intensive Care in Europe (EPICE) cohort, 2011-2012.

SETTING

Nineteen regions in 11 European countries.

PATIENTS

All infants born between 24+0 and 31+6 weeks' gestational age (GA) with a diagnosis of IPH.

MAIN OUTCOME MEASURES

Mortality rate with multivariable analysis after adjustment for GA, antenatal steroids and gender. WLST policies were described among NICUs and within countries.

RESULTS

Among 6828 infants born alive between 24+0 and 31+6 weeks' GA and without congenital anomalies admitted to NICUs, IPH was diagnosed in 234 infants (3.4%, 95% CI 3.3% to 3.9%) and 138 of them (59%) died. The median age at death was 6 days (3-13). Mortality rates varied significantly between countries (extremes: 30%-81%; p<0.004) and most infants (69%) died after WLST. After adjustment and with reference to the UK, mortality rates were significantly higher for France, Denmark and the Netherlands, with ORs of 8.8 (95% CI 3.3 to 23.6), 5.9 (95% CI 1.6 to 21.4) and 4.8 (95% CI 1.1 to 8.9). There were variations in WLST between European regions and countries.

CONCLUSION

In infants with IPH, rates of death before discharge and death after WLST varied between European countries. These variations in mortality impede studying reliable outcomes in infants with IPH across European countries and encourage reflection of clinical practices of WLST across European units.

Iron homeostasis and post-hemorrhagic hydrocephalus: a review

Iron physiology is regulated by a complex interplay of extracellular transport systems, coordinated transcriptional responses, and iron efflux mechanisms. Dysregulation of iron metabolism can result in defects in myelination, neurotransmitter synthesis, and neuronal maturation. In neonates, germinal matrix-intraventricular hemorrhage (GMH-IVH) causes iron overload as a result of blood breakdown in the ventricles and brain parenchyma which can lead to post-hemorrhagic hydrocephalus (PHH). However, the precise mechanisms by which GMH-IVH results in PHH remain elusive. Understanding the molecular determinants of iron homeostasis in the developing brain may lead to improved therapies. This manuscript reviews the various roles iron has in brain development, characterizes our understanding of iron transport in the developing brain, and describes potential mechanisms by which iron overload may cause PHH and brain injury. We also review novel preclinical treatments for IVH that specifically target iron. Understanding iron handling within the brain and central nervous system may provide a basis for preventative, targeted treatments for iron-mediated pathogenesis of GMH-IVH and PHH.

Deferoxamine Prevents Neonatal Posthemorrhagic Hydrocephalus Through Choroid Plexus-Mediated Iron Clearance

Posthemorrhagic hydrocephalus occurs in up to 30% of infants with high-grade intraventricular hemorrhage and is associated with the worst neurocognitive outcomes in preterm infants. The mechanisms of posthemorrhagic hydrocephalus after intraventricular hemorrhage are unknown; however, CSF levels of iron metabolic pathway proteins including hemoglobin have been implicated in its pathogenesis. Here, we develop an animal model of intraventricular hemorrhage using intraventricular injection of hemoglobin at post-natal day 4 that results in acute and chronic hydrocephalus, pathologic choroid plexus iron accumulation, and subsequent choroid plexus injury at post-natal days 5, 7, and 15. This model also results in increased expression of aquaporin-1, Na+/K+/Cl- cotransporter 1, and Na+/K+/ATPase on the apical surface of the choroid plexus 24 h post-intraventricular hemorrhage. We use this model to evaluate a clinically relevant treatment strategy for the prevention of neurological sequelae after intraventricular hemorrhage using intraventricular administration of the iron chelator deferoxamine at the time of hemorrhage. Deferoxamine treatment prevented posthemorrhagic hydrocephalus for up to 11 days after intraventricular hemorrhage and prevented the development of sensorimotor gating deficits. In addition, deferoxamine treatment facilitated acute iron clearance through the choroid plexus and subsequently reduced choroid plexus iron levels at 24 h with reversal of hemoglobin-induced aquaporin-1 upregulation on the apical surface of the choroid plexus. Intraventricular administration of deferoxamine at the time of intraventricular hemorrhage may be a clinically relevant treatment strategy for preventing posthemorrhagic hydrocephalus and likely acts through promoting iron clearance through the choroid plexus to prevent hemoglobin-induced injury.

Decision-making for extremely preterm infants with severe hemorrhages on head ultrasound: Science, values, and communication skills

Severe intracranial hemorrhages are not rare in extremely preterm infants. They occur early, generally when babies require life-sustaining interventions. This may lead to ethical discussions and decision-making about levels of care. Prognosis is variable and depends on the extent, location, and laterality of the lesions, and, importantly also on the subsequent occurrence of other clinical complications or progressive ventricular dilatation. Decision-making should depend on prognosis and parental values. This article will review prognosis and the uncertainty of outcomes for different lesions and provide an outline of ways to conduct an ethically appropriate discussion on the decision of whether to continue life sustaining therapy. It is possible to communicate in a compassionate and honest way with parents and engage in decision-making, focussing on personalized information and decisions, and on function, as opposed to diagnosis.

Neurodevelopmental Outcome at Two Years for Preterm Infants With Intraventricular Hemorrhage: A Case-Control Study

BACKGROUND

High-grade intraventricular hemorrhage (IVH), including grade III and grade IV IVH, is known to impact neurodevelopmental outcome of preterm infants, but prognosis remains difficult to establish due to confounding factors and significant variations in the reported outcomes. The aim of this study was to compare the neurodevelopmental outcome of preterm infants with or without severe IVH.

METHODS

A retrospective case-control study was conducted including preterm infants with gestational age <32 weeks hospitalized between 2009 and 2017 in a level III neonatal intensive care unit. This study included 73 cases with high-grade IVH and 73 controls who were matched to cases, based on the same gestational age, birth weight, sex, and year of birth. The neurodevelopmental outcome was compared at two years of age corrected for prematurity between cases and controls. Neurodevelopmental impairment was defined as cerebral palsy, hearing deficiency, visual impairment, or developmental delay. Multivariate analysis was used to identify whether high-grade IVH was an independent risk factor for neurodevelopmental impairment.

RESULTS

In univariate analysis, high-grade IVH was associated with death or poor neurodevelopmental outcome at two years of age corrected for prematurity (odds ratio [OR], 16.3; 95% confidence interval [CI], 5.93 to 57.8; P < 0.001), and this association remained significant after adjusting for confounding factors including neonatal infection and bronchopulmonary dysplasia in multivariate analysis (OR, 8.71; 95% CI, 2.48 to 38.09; P = 0.002).

CONCLUSIONS

This study highlights the impact of high-grade IVH as an independent risk factor of poor neurodevelopmental outcomes in very preterm infants and suggests that early interventions could improve the prognosis of these infants.

Preterm Brain Injury and Neurodevelopmental Outcomes: A Meta-analysis

CONTEXT

Preterm brain injuries are common; neurodevelopmental outcomes following contemporary neonatal care are continually evolving.

OBJECTIVE

To systematically review and meta-analyze neurodevelopmental outcomes among preterm infants after intraventricular hemorrhage (IVH) and white matter injury (WMI).

DATA SOURCES

Published and grey literature were searched across 10 databases between 2000 and 2021.

STUDY SELECTION

Observational studies reporting 3-year neurodevelopmental outcomes for preterm infants with IVH or WMI compared with preterm infants without injury.

DATA EXTRACTION

Study characteristics, population characteristics, and outcome data were extracted.

RESULTS

Thirty eight studies were included. There was an increased adjusted risk of moderate-severe neurodevelopmental impairment after IVH grade 1 to 2 (adjusted odds ratio 1.35 [95% confidence interval 1.05-1.75]) and IVH grade 3 to 4 (adjusted odds ratio 4.26 [3.25-5.59]). Children with IVH grade 1 to 2 had higher risks of cerebral palsy (odds ratio [OR] 1.76 [1.39-2.24]), cognitive (OR 1.79 [1.09-2.95]), hearing (OR 1.83 [1.03-3.24]), and visual impairment (OR 1.77 [1.08-2.9]). Children with IVH grade 3 to 4 had markedly higher risks of cerebral palsy (OR 4.98 [4.13-6.00]), motor (OR 2.7 [1.52-4.8]), cognitive (OR 2.3 [1.67-3.15]), hearing (OR 2.44 [1.42-4.2]), and visual impairment (OR 5.42 [2.77-10.58]). Children with WMI had much higher risks of cerebral palsy (OR 14.91 [7.3-30.46]), motor (OR 5.3 [3-9.36]), and cognitive impairment (OR 3.48 [2.18-5.53]).

LIMITATIONS

Heterogeneity of outcome data.

CONCLUSIONS

Mild IVH, severe IVH, and WMI are associated with adverse neurodevelopmental outcomes. Utilization of core outcome sets and availability of open-access study data would improve our understanding of the nuances of these outcomes.

The chance of spontaneous patent ductus arteriosus closure in preterm infants born before 32 weeks of gestation is high and continues to increase until 5 years of follow-up

AIM

The primary aim was to estimate premature infants' spontaneous patent ductus arteriosus closure rate. Secondly, to identify criteria associated with the chance of spontaneous closure.

METHODS

We performed a retrospective cohort study of 167 infants born before 32 weeks of gestation and diagnosed with a patent ductus arteriosus between 1 January 2008 and 31 December 2017. The spontaneous patent ductus arteriosus closure event rate was evaluated using the Kaplan-Meier estimator.

RESULTS

The spontaneous closure rate within the first year of life was 66% (95% CI 58%-73%), increasing to 80% (95% CI 72%-86%) five years after birth. When including both spontaneous closure and closure following treatment, 96% (95% CI 86%-100%) closed within 5 years after birth. The chance of spontaneous closure was reduced in the case of a large patent ductus arteriosus: OR 0.16 (95% CI 0.05-0.52), left atrial enlargement: OR 0.16 (95% CI 0.05-0.51), and pulmonary hypertension: OR 0.23 (95% CI 0.07-0.74).

CONCLUSION

The chance of spontaneous closure in premature infants born between 23 and 32 weeks of gestation was high, and the incidence continued increasing until 5 years of follow-up.

Early neurodevelopmental follow-up in the NICHD neonatal research network: Advancing neonatal care and outcomes, opportunities for the future

At the inception of the Eunice Kennedy Shriver National Institute of Child Health and Development Neonatal Research Network (NRN), provision of care for extremely preterm (EPT) infants was considered experimental. The NRN Follow-up Study Group, initiated in 1993, developed infrastructure with certification processes and standards, allowing the NRN to assess 2-year outcomes for EPT and to provide important metrics for randomized clinical trials. This chapter will review the NRN Follow-up Study Group's contributions to understanding factors related to improved neurodevelopmental, behavioral, and social-emotional outcomes of EPT infants. We will also discuss follow up challenges, including reassessing which outcomes are most meaningful for parents and investigators. Finally, we will explore how outcome studies have informed clinical decisions and ethical considerations, given limitations of prediction of complex later childhood outcomes from early neurodevelopmental findings.

Survey of UK clinicians' approaches to decision making in neonatal intestinal failure

Background

Outcomes for neonatal intestinal failure (IF) have improved significantly over the past two decades, however, there is no consensus for decision making among UK paediatric subspecialists.

Objectives

The aim was to describe clinician's attitudes to decision making in neonatal IF and examine variation between subspecialties.

Methods

Neonatologists, paediatric surgeons and gastroenterologists were surveyed electronically. They were asked if they would recommend active or palliative care or allow the parents to decide in several scenarios; or if they considered treatment morally obligatory or impermissible.

Results

Of 147 respondents, 81% of gastroenterologists would recommend active care (34.6% regardless of parental decision) for a term infant with total gut Hirschsprung's compared with 46% and 33% of surgeons and neonatologists. No gastroenterologist would recommend palliation while 23% of both neonatologists and surgeons would. Similarly, 77% of surgeons and 73% of neonatologists would recommend palliation for a 28-week infant with IF and bilateral parenchymal haemorrhages compared with 27% of gastroenterologists.Prognostic estimates also varied. A term baby with IF was estimated to have a survival of >80% at 5 years by 58% of gastroenterologists compared with 11.5% and 2.7% of surgeons and neonatologists. Only 11.5% of surgeons and 2.6% of neonatologist believed a 26-week preterm with IF would have a 5-year survival >60% compared with 59% of gastroenterologists.

Conclusion

There is substantial variation in views about outcomes and management choices both within and between specialties; with gastroenterologists being consistently more positive. This is likely to lead to unjustified variation in counselling and parental choices.

Thrombin Preconditioning Improves the Therapeutic Efficacy of Mesenchymal Stem Cells in Severe Intraventricular Hemorrhage Induced Neonatal Rats

Severe intraventricular hemorrhage (IVH) remains a major cause of high mortality and morbidity in extremely preterm infants. Mesenchymal stem cell (MSC) transplantation is a possible therapeutic option, and development of therapeutics with enhanced efficacy is necessary. This study investigated whether thrombin preconditioning improves the therapeutic efficacy of human Wharton’s jelly-derived MSC transplantation for severe neonatal IVH, using a rat model. Severe neonatal IVH was induced by injecting 150 μL blood into each lateral ventricle on postnatal day (P) 4 in Sprague-Dawley rats. After 2 days (P6), naïve MSCs or thrombin-preconditioned MSCs (1 × 10⁵/10 μL) were transplanted intraventricularly. After behavioral tests, brain tissues and cerebrospinal fluid of P35 rats were obtained for histological and biochemical analyses, respectively. Thrombin-preconditioned MSC transplantation significantly reduced IVH-induced ventricular dilatation on in vivo magnetic resonance imaging, which was coincident with attenuations of reactive gliosis, cell death, and the number of activated microglia and levels of inflammatory cytokines after IVH induction, compared to naïve MSC transplantation. In the behavioral tests, the sensorimotor and memory functions significantly improved after transplantation of thrombin-preconditioned MSCs, compared to naïve MSCs. Overall, thrombin preconditioning significantly improves the therapeutic potential and more effectively attenuates brain injury, including progressive ventricular dilatation, gliosis, cell death, inflammation, and neurobehavioral functional impairment, in newborn rats with induced severe IVH than does naïve MSC transplantation.

Comparison of Papile versus Laterality-Based Al-Abdi System to Predict Neurodevelopmental Impairment in Extreme Preterm Infants after Severe Germinal Matrix Hemorrhage-Intraventricular Hemorrhage: A Retrospective Comparative Observational Study

BACKGROUND AND PURPOSE

The traditional Papile classification system for severe germinal matrix hemorrhage-intraventricular hemorrhage is limited in objectivity and interrater variability for accurate prediction of neurodevelopmental impairment in extremely preterm infants. Many extremely preterm infants with severe germinal matrix hemorrhage-intraventricular hemorrhage are still offered "redirection of care" in spite of the recent evidence suggesting that many of these infants can have normal outcomes. Therefore, it is important to consider the laterality and extent of brain hemisphere involvement while classifying severe germinal matrix hemorrhage-intraventricular hemorrhage to predict neurodevelopmental impairment. The aim of the present study was to compare the Al-Abdi system with the Papile system for their accuracy in predicting neurodevelopmental impairment in extremely preterm infants with severe germinal matrix hemorrhage-intraventricular hemorrhage.

MATERIALS AND METHODS

This is a retrospective study of extremely preterm infants with severe germinal matrix hemorrhage-intraventricular hemorrhage admitted to a tertiary neonatal intensive care unit (2006-2016). Cranial sonograms were independently re-reviewed by 2 radiologists as per the Al-Abdi system. The prognostic statistical indices for both systems to predict neurodevelopmental impairment were calculated.

RESULTS

A total of 91 infants with severe germinal matrix hemorrhage-intraventricular hemorrhage survived, and 83 (median gestational age, 26.3 weeks; and median birth weight, 890 g) completed developmental assessment. The receiver operating characteristic areas under the curve to predict neurodevelopmental impairment by the Papile versus Al-Abdi systems were 0.702 versus 0.723, respectively (P = .474). Corresponding Al-Abdi cutoff scores of 19, 20, 21, and 22 demonstrated increased specificity (76.36%-85.45%) and correct classification (69.88%-72.29%) to predict moderate-to-severe neurodevelopmental impairment.

CONCLUSIONS

The Al-Abdi system is comparable with the Papile system for predicting neurodevelopmental impairment for extremely preterm infants with severe germinal matrix hemorrhage-intraventricular hemorrhage, with higher Al-Abdi scores being more specific. This finding may prove useful for neonatal health care providers and parents in their decision regarding "continuation of care." Future multicentric studies are warranted to ascertain the validity of individual Al-Abdi scores.

The COPE-Trial-Communicating prognosis to parents in the neonatal ICU: Optimistic vs. PEssimistic: study protocol for a randomized controlled crossover trial using two different scripted video vignettes to explore communication preferences of parents of preterm infants

BACKGROUND

One of the numerous challenges preterm birth poses for parents and physicians is prognostic disclosure. Prognoses are based on scientific evidence and medical experience. They are subject to individual assessment and will generally remain uncertain with regard to the individual. This can result in differences in prognostic framing and thus affect the recipients' perception. In neonatology, data on the effects of prognostic framing are scarce. In particular, it is unclear whether parents prefer a more optimistic or a more pessimistic prognostic framing.

OBJECTIVE

To explore parents' preferences concerning prognostic framing and its effects on parent-reported outcomes and experiences. To identify predictors (demographic, psychological) of parents' communication preferences.

DESIGN, SETTING, PARTICIPANTS

Unblinded, randomized controlled crossover trial (RCT) at the Division of Neonatology of the University Medical Center Mainz, Germany, including German-speaking parents or guardians of infants born preterm between 2010 and 2019 with a birth weight < 1500 g. Inclusion of up to 204 families is planned, with possible revision according to a blinded sample size reassessment.

INTERVENTION

Embedded in an online survey and in pre-specified order, participants will watch two video vignettes depicting a more optimistic vs. a more pessimistic framing in prognostic disclosure to parents of a preterm infant. Apart from prognostic framing, all other aspects of physician-parent communication are standardized in both videos.

MAIN OUTCOMES AND MEASURES

At baseline and after each video, participants complete a two-part online questionnaire (baseline and post-intervention). Primary outcome is the preference for either a more optimistic or a more pessimistic prognostic framing. Secondary outcomes include changes in state-anxiety (STAI-SKD), satisfaction with prognostic framing, evaluation of prognosis, future optimism and hope, preparedness for shared decision-making (each assessed using customized questions), and general impression (customized question), professionalism (adapted from GMC Patient Questionnaire) and compassion (Physician Compassion Questionnaire) of the consulting physician.

DISCUSSION

This RCT will explore parents' preferences concerning prognostic framing and its effects on physician-parent communication. Results may contribute to a better understanding of parental needs in prognostic disclosure and will be instrumental for a broad audience of clinicians, scientists, and ethicists.

TRIAL REGISTRATION

German Clinical Trials Register DRKS00024466 . Registered on April 16, 2021.

Intracranial Hemorrhage and 2-Year Neurodevelopmental Outcomes in Infants Born Extremely Preterm

OBJECTIVES

To determine the incidence, timing, progression, and risk factors for intracranial hemorrhage (ICH) in infants 24^0/7 to 27^6/7 weeks of gestational age and to characterize the association between ICH and death or neurodevelopmental impairment (NDI) at 2 years of corrected age.

STUDY DESIGN

Infants enrolled in the Preterm Erythropoietin Neuroprotection Trial had serial cranial ultrasound scans performed on day 1, day 7-9, and 36 weeks of postmenstrual age to evaluate ICH. Potential risk factors for development of ICH were examined. Outcomes included death or severe NDI as well as Bayley Scales of Infant and Toddler Development, 3rd Edition, at 2 years of corrected age.

RESULTS

ICH was identified in 38% (n = 339) of 883 enrolled infants. Multiple gestation and cesarean delivery reduced the risk of any ICH on day 1. Risk factors for development of bilateral Grade 2, Grade 3, or Grade 4 ICH at day 7-9 included any ICH at day 1; 2 or more doses of prenatal steroids decreased risk. Bilateral Grade 2, Grade 3, or Grade 4 ICH at 36 weeks were associated with previous ICH at day 7-9. Bilateral Grade 2, any Grade 3, and any Grade 4 ICH at 7-9 days or 36 weeks of postmenstrual age were associated with increased risk of death or severe NDI and lower Bayley Scales of Infant and Toddler Development, 3rd Edition, scores.

CONCLUSIONS

Risk factors for ICH varied by timing of bleed. Bilateral and increasing grade of ICH were associated with death or NDI in infants born extremely preterm.

Cerebrospinal fluid NCAM-1 concentration is associated with neurodevelopmental outcome in post-hemorrhagic hydrocephalus of prematurity

OBJECTIVE

Efforts directed at mitigating neurological disability in preterm infants with intraventricular hemorrhage (IVH) and post hemorrhagic hydrocephalus (PHH) are limited by a dearth of quantifiable metrics capable of predicting long-term outcome. The objective of this study was to examine the relationships between candidate cerebrospinal fluid (CSF) biomarkers of PHH and neurodevelopmental outcomes in infants undergoing neurosurgical treatment for PHH.

STUDY DESIGN

Preterm infants with PHH were enrolled across the Hydrocephalus Clinical Research Network. CSF samples were collected at the time of temporizing neurosurgical procedure (n = 98). Amyloid precursor protein (APP), L1CAM, NCAM-1, and total protein (TP) were compared in PHH versus control CSF. Fifty-four of these PHH subjects underwent Bayley Scales of Infant Development-III (Bayley-III) testing at 15-30 months corrected age. Controlling for false discovery rate (FDR) and adjusting for post-menstrual age (PMA) and IVH grade, Pearson's partial correlation coefficients were used to examine relationships between CSF proteins and Bayley-III composite cognitive, language, and motor scores.

RESULTS

CSF APP, L1CAM, NCAM-1, and TP were elevated in PHH over control at temporizing surgery. CSF NCAM-1 was associated with Bayley-III motor score (R = -0.422, p = 0.007, FDR Q = 0.089), with modest relationships noted with cognition (R = -0.335, p = 0.030, FDR Q = 0.182) and language (R = -0.314, p = 0.048, FDR Q = 0.194) scores. No relationships were observed between CSF APP, L1CAM, or TP and Bayley-III scores. FOHR at the time of temporization did not correlate with Bayley-III scores, though trends were observed with Bayley-III motor (p = 0.0647 and R = -0.2912) and cognitive scores (p = 0.0506 and R = -0.2966).

CONCLUSION

CSF NCAM-1 was associated with neurodevelopment in this multi-institutional PHH cohort. This is the first report relating a specific CSF protein, NCAM-1, to neurodevelopment in PHH. Future work will further investigate a possible role for NCAM-1 as a biomarker of PHH-associated neurological disability.

Risk factors and short-term complications of high-grade intraventricular hemorrhages in preterm neonates in training hospitals of Alborz

Objectives

The aim of this study is to determine risk factors and short-term complications of high-grade intraventricular hemorrhages (IVHs) in preterm neonates. Other topics of investigation include the increase in complications of IVH with its severity and the effect of IVH risk factors on the severity of IVH.

Materials & Methods

We conducted a retrospective case-control study of 436 consecutive preterm neonates with high-grade (3, 4) IVHs admitted in training hospitals of Alborz University in Karaj, Iran, from 2012 to 2017. The risk factors and short-term complications were assessed and analyzed in the subjects by SPSS 19.

Results

Out of 10 000 eligible neonates, we identified 1203 premature infants with IVH. A total of 436 infants with IVH grades 3 and 4 were allocated to the case group. The control group consisted of 767 infants with IVH grades 1 and 2. This study revealed that the most common risk factors of IVH include lack of corticosteroid use in 67.2%, low Apgar score in 10%, and surfactant use in 5.7% of the patients. Ten percent (31 cases) had short-term complications (18 hydrocephalus and 13 death cases). Male gender (P = .006) and lower gestational age (P = .0001) contributed to higher grades of IVH.

Conclusion

According to the results obtained in this study, it may be concluded that the lack of corticosteroid use is the most common risk factor for IVH, and short-term complications may be seen in one-tenth of the cases.

Low-grade intraventricular hemorrhage of preterm infants: neurodevelopmental and motor outcome

Intraventricular hemorrhage (IVH) is a main complication of prematurity, inversely associated with gestational age and birth weight. Low-grade IVH (I and II), diagnosed by cranial ultrasound, had long been considered rather not to affect neurodevelopmental and motor outcome, a view challenged by several literature reports. However, diversity in studies design, periods of subjects' collection, cohort characteristics, demographic data, maternal or neonatal comorbidities, neuroimaging methods, evaluation tools, short-or-long-term follow-up by the same or different examiners, as well as other parameters and confounders make comparisons among reports very difficult, not allowing solid conclusions. Older, but also newer investigations claim both possible outcomes: impairment or not of cognitive and motor abilities in very preterm infants with low-grade IVH. Thus, the current suggestion in the relevant literature is not to rely only on the results of cranial ultrasounds, but to also implement classic, or even more advanced MRI techniques at term equivalent age to preterm infants with grade I or II IVH. In addition, the continuation of close follow-up during school age is warranted.

The association of early postnatal weight loss with outcome in extremely low birth weight infants

BACKGROUND

To compare outcomes of extremely low birth weight (ELBW) infants having different weight losses in the first 3 days of life.

METHODS

One hundred and twenty six ELBW infants were evaluated retrospectively for weight loss percentages on the third day of life compared to their birth weight. We examined the weight loss on the third day of life compared to the birth weight for the ELBW infants and tested its association with mortality and morbidities. The mortality was subgrouped as overall mortality and mortality in the first 7 days of life. The morbidities were patent ductus arteriosus (PDA), intraventricular hemorrhage (IVH) and bronchopulmonary dysplasia (BPD). BPD was defined as need for supplemental oxygen at 36 weeks' postconceptional age. We grouped the infants into four quartiles according to weight loss percentage on the third day of life: Group 1 (Quartile 1), infants with weight loss of 0-3% of birth weight; Group 2 (Quartile 2); infants with weight loss of 3.1-7.5%, Group 3 (Quartile 3), infants with weight loss of 7.51-12%; and Group 4 (Quartile 4), infants with weight loss of more than 12%. The mortality and morbidities were analyzed according to these groups and other risk factors.

RESULTS

Overall mortality and mortality in the first 7 days of life were significantly higher in Groups 1 (36% and 27%) and 4 (43% and 24%), compared to Groups 2 (10% and 10%) and 3 (18% and 9%), respectively.

CONCLUSION

Weight loss less than 3% and more than 12% was significantly associated with an increase in mortality. There was a positive correlation between weight loss on the third day of life and IVH.

CONCLUSION

Inappropriate weight loss in ELBW infants is associated with increased mortality and IVH. Appropriate weight loss can improve outcomes in this population.

Predictive Value of Cranial Ultrasound for Neurodevelopmental Outcomes of Very Preterm Infants with Brain Injury

Background:

Compared with full-term infants, very preterm infants are more vulnerable to injury and long-term disability and are at high risk of death. The predictive value of ultrasound and imaging on the neurodevelopment is one of the hot topics. This study aimed to investigate the relationship between cranial ultrasound (cUS) variables and neurodevelopmental outcomes of very preterm infants.

Methods:

Totally 129 very preterm infants (gestational age ≤28 weeks) in neonatal intensive care unit of Hunan Children's Hospital between January 2012 and November 2014 were included in this retrospective study. Serial cUS (weekly before discharge and monthly after discharge) was performed on the infants until 6 months or older. Magnetic resonance imaging (MRI) was performed on the infants at approximately the term-equivalent age. The mental developmental index (MDI) and psychomotor developmental index (PDI) were followed up until the infants were 24 months or older. The relationship between brain injury and MDI/PDI scores was analyzed.

Results:

The consistency rate between cUS and MRI was 88%. At the first cUS, germinal matrix hemorrhage (GMH) Grades 3 and 4, hospitalization duration, and weight are significantly correlated with MDI/PDI and prognosis (MDI: odds ratio [OR] = 8.415, 0.982, and 0.042, P = 0.016, 0.000, and 0.004; PDI: OR = 7.149, 0.978, and 0.012, P = 0.025, 0.000, and 0.000, respectively). At the last cUS, gestational age, extensive cystic periventricular leukomalacia (c-PVL), and moderate and severe hydrocephaly are significantly correlated with MDI (OR = 0.292, 60.220, and 170.375, P = 0.004, 0.003, and 0.000, respectively). Extensive c-PVL and moderate and severe hydrocephaly are significantly correlated with PDI (OR = 76.861 and 116.746, P = 0.003 and 0.000, respectively).

Conclusions:

Very premature infants with GMH Grades 3 and 4, short hospitalization duration, and low weight have low survival rates and poorly developed brain nerves. Cerebral palsy can result from severe cerebral hemorrhage, moderate and severe hydrocephaly, and extensive c-PVL. The sustained, inhomogeneous echogenicity of white matter may suggest subtle brain injury.

Changing definitions of long-term follow-up: Should "long term" be even longer?

There have been amazing changes in outcomes of preterm (PT) infants in the past decades. Whereas early studies reported only survival rates, Dr. Julius Hess published the first outcome study of PT infants in Chicago in 1953. Dr. Lubchenco then published the 10-year follow-up of premature infants born in 1947-1953 and identified a 68% handicap rate. As a result of these early studies, the importance of evaluating NICU graduates both for surveillance and as an outcome of trials was recognized. During the 1970s, there was a gradual expansion in the number of follow-up programs in the United States (US) with an increasing number of follow-up studies published. In the 1980s, the importance of multicenter clinical research networks was recognized and the NICHD Neonatal Research Network (NRN) was initiated in 1986. Follow-up protocols, definitions, and outcomes have evolved over the last 30 years and will be reviewed with a focus on NICHD NRN studies.

The Vulnerable Newborn Brain: Imaging Patterns of Acquired Perinatal Injury

BACKGROUND

Over the past two decades, imaging techniques have allowed for better visualization of the newborn brain. This has enabled us to detect patterns, understand mechanisms and guide diagnosis and treatment.

OBJECTIVES

The purpose of this review is to discuss imaging characteristics of acquired perinatal brain injury.

METHODS

Through literature review and the author's research, this review assesses published data on the distinct imaging patterns that occur in the neonatal period due to acquired brain insults.

RESULTS

In the term brain, susceptibility to hypoxia-ischemia, hypoglycemia and hyperbilirubinemia results in unique patterns of injury. Stroke commonly occurs in the newborn period. Infections, especially viral, have distinct patterns of white matter injury. In the preterm brain, white matter injury occurs commonly and is affected by postnatal growth, stress and infection. The cerebellum is uniquely vulnerable during this period, with resultant hemorrhages in almost half of preterm infants. Cerebellar growth is affected by intraventricular hemorrhage, drugs and placental pathology. Periventricular hemorrhagic infarction is the most serious consequence of the spectrum of intraventricular hemorrhage and results in profound disabilities.

CONCLUSIONS

Taken together, the acquired perinatal brain injuries can have lifelong devastating consequences, so the search for therapies must continue.

Integrating neurocritical care approaches into neonatology: should all infants be treated equitably?

To improve the neurologic outcomes for infants with brain injury, neonatal providers are increasingly implementing neurocritical care approaches into clinical practice. Term infants with brain injury have been principal beneficiaries of neurologically-integrated care models to date, as evidenced by the widespread adoption of therapeutic hypothermia protocols for hypoxic-ischemic encephalopathy. Innovative therapeutic and diagnostic support for very low birth weight infants with brain injury has lagged behind. Given that concern for significant future neurodevelopmental impairment can lead to decisions to withdraw life supportive care at any gestational age, providing families with accurate prognostic information is essential for all infants. Current variable application of multidisciplinary neurocritical care approaches to infants at different gestational ages may be ethically problematic and reflect distinct perceptions of brain injury for infants born extremely premature.

Periventricular/Intraventricular Hemorrhage and Neurodevelopmental Outcomes: A Meta-analysis

CONTEXT

Periventricular/intraventricular hemorrhage (PIVH) is a common short-term morbidity in preterm infants, but its long-term neurodevelopmental impact, particularly with mild PIVH, remains unclear.

OBJECTIVE

To systematically review and meta-analyze the neurodevelopmental outcomes of preterm infants ≤34 weeks' gestation with mild and severe PIVH, compared with no PIVH.

DATA SOURCES

Medline, Embase, CINAHL, and PsychINFO databases from January 2000 through June 2014.

STUDY SELECTION

Studies reporting long-term neurodevelopmental outcomes based on severity of PIVH were included.

DATA EXTRACTION

Study characteristics, inclusion/exclusion criteria, exposures, and outcome assessment data extracted independently by 2 coauthors.

RESULTS

The pooled unadjusted odds ratios of the primary outcome of death or moderate-severe neurodevelopmental impairment (NDI) were higher with both mild (1.48, 95% CI 1.26-1.73; 2 studies) and severe PIVH (4.72, 4.21-5.31; 3 studies); no studies reported adjusted odds ratios. Among survivors, odds of moderate-severe NDI were higher with mild and severe PIVH in both unadjusted (1.75, 1.40-2.20; 3 studies; 3.36, 3.06-3.68; 5 studies) and adjusted (1.39, 1.09-1.77; 3 studies; 2.44, 1.73-3.42; 2 studies) pooled analyses. Adjusted odds of cerebral palsy and cognitive delay were higher with severe but not mild PIVH.

LIMITATIONS

Only observational studies were included. Fifteen of 21 included studies had a moderate-high risk of bias.

CONCLUSIONS

Mild and severe PIVH are associated with progressively higher odds of death or moderate-severe NDI compared with no PIVH, but no studies adjusted for confounders. Among survivors, mild PIVH was associated with higher odds of moderate-severe NDI compared with no PIVH.

Low-grade intraventricular hemorrhage disrupts cerebellar white matter in preterm infants: evidence from diffusion tensor imaging

INTRODUCTION

Recent diffusion tensor imaging (DTI) studies have demonstrated that leakage of hemosiderin into cerebrospinal fluid (CSF), which is caused by high-grade intraventricular hemorrhage (IVH), can affect cerebellar development in preterm born infants. However, a direct effect of low-grade IVH on cerebellar development is unknown. Thus, we evaluated the cerebellar and cerebral white matter (WM) of preterm infants with low-grade IVH.

METHODS

Using DTI tractography performed at term-equivalent age, we analyzed 42 infants who were born less than 30 weeks gestational age (GA) at birth (22 with low-grade IVH, 20 without). These infants were divided into two birth groups depending on GA, and we then compared the presence and absence of IVH which was diagnosed by cerebral ultrasound (CUS) within 10 days after birth or conventional magnetic resonance imaging (MRI) at term-equivalent age in each group. Fractional anisotropy (FA) and apparent diffusion coefficient (ADC) at the superior cerebellar peduncle (SCP), middle cerebellar peduncle (MCP), motor tract, and sensory tract were measured.

RESULTS

In the SCP, preterm born infants with IVH had lower FA values compared with infants without IVH. In particular, younger preterm birth with IVH had lower FA values in the SCP and motor tract and higher ADC values in the MCP.

CONCLUSION

Low-grade IVH impaired cerebellar and cerebral WM, especially in the SCP. Moreover, younger preterm infants exhibited greater disruptions to cerebellar WM and the motor tract than infants of older preterm birth.

Predictors of neurodevelopmental outcomes in preterm infants with intraparenchymal hemorrhage

OBJECTIVE

To determine which neuroimaging, clinical and sociodemographic factors predict neurodevelopment at 18-22 months age among extremely preterm infants with intraparenchymal hemorrhage (IPH).

STUDY DESIGN

Cranial ultrasounds performed before 42 days of age and cranial ultrasounds/magnetic resonance images of the brain performed near discharge were reviewed for hemorrhage location and other abnormalities. Clinical and sociodemographic factors were extracted from existing databases. The primary outcome was presence of cerebral palsy (CP) and the secondary outcome was cognitive development (Bayley Scales of Infant Development).

RESULT

Of 1168 infants (<1000 g or <27 weeks), 141 infants had an IPH and 48 infants were seen in follow-up. All infants with extensive hemorrhages (involving three or more lobes) developed CP. In early imaging (before 42 days of age), ventriculomegaly, intraventricular hemorrhage (IVH) and extensive hemorrhage were predictors of CP. In imaging performed near discharge, ventriculomegaly, intraventricular echodensity and having a ventricular shunt were predictors of CP. Clinical, imaging and sociodemographic factors were not associated with low cognitive score.

CONCLUSION

In preterm infants surviving with IPH, extensive hemorrhage, ventriculomegaly, IVH and having a shunt increased the risk of developing CP.

Outcomes of extremely preterm infants following severe intracranial hemorrhage

OBJECTIVE

Severe intracranial hemorrhage (ICH) is an important prognostic variable in extremely preterm (EPT) infants. We examined imaging and clinical variables that predict outcomes in EPT infants with severe ICH.

STUDY DESIGN

Retrospective analysis of 353 EPT infants with severe ICH. Outcomes were compared by examining: (i) unilateral vs bilateral ICH; and (ii) presence vs absence of hemorrhagic parenchymal infarction (HPI). Regression analyses identified variables associated with death or neurodevelopmental impairment (NDI).

RESULT

Bilateral ICH and HPI had higher rates of adverse outcomes and were independently associated with death/NDI. HPI was the most important variable for infants of lower birth weight, and bilateral ICH for larger infants. For infants surviving to 36 weeks, shunt placement was most associated with death/NDI.

CONCLUSION

Bilateral ICH and the presence of HPI in EPT infants with severe ICH are associated with death/NDI, though the importance depends on birth weight and survival to 36 weeks.

Prevalence and neonatal factors associated with autism spectrum disorders in preterm infants

OBJECTIVES

To determine the prevalence of autism spectrum disorders (ASD) across gestational age, examine the risk of ASD by gestational age controlling for other risk factors, and identify potential risk factors in the neonatal intensive care unit.

STUDY DESIGN

A retrospective cohort of infants born at ≥ 24 weeks between January 1, 2000, and December 31, 2007 at 11 Kaiser Permanente Northern California hospitals (n = 195,021). ASD cases were defined by a diagnosis made at a Kaiser Permanente ASD evaluation center, by a clinical specialist, or by a pediatrician. Cox proportional hazards regression models were used to evaluate the association between gestational age and ASD as well as potential risk factors in the neonatal intensive care unit and ASD.

RESULTS

The prevalence of ASD in infants <37 weeks was 1.78% compared with 1.22% in infants born ≥ 37 weeks (P < .001). Compared with term infants, infants born at 24-26 weeks had an adjusted hazard ratio (HR) for a diagnosis of ASD of 2.7 (95% CI 1.5-5.0). Infants born at 27-33 weeks (adjusted HR 1.4, 95% CI 1.1-1.8) and 34-36 weeks (adjusted HR 1.3, 95% CI 1.1-1.4) were also at increased risk. High frequency ventilation and intracranial hemorrhage were associated with ASD in infants < 34 weeks.

CONCLUSIONS

ASD was ~ 3 times more prevalent in infants <27 weeks compared with term infants. Each week of shorter gestation was associated with an increased risk of ASD. High frequency ventilation and intracranial hemorrhage were associated with ASD among infants <34 weeks.

Visual function in preterm infants: visualizing the brain to improve prognosis

Considerable development of the visual system occurs in the third trimester of life, a time when very preterm-born infants are in a neonatal intensive care unit (NICU). Their very early birth during a period of rapid and marked neurodevelopment and their clinical course makes them a very high-risk population. A range of different events impacts brain development and the visual system, leading to significant long-term visual dysfunction. Improved neuroimaging techniques provide an important window on the early brain and visual system development of these vulnerable infants. Greater understanding of the etiology of visual impairment subsequent to preterm birth and the timing of critical processes will allow early recognition and the earlier implementations of interventions. In the longer term, this will help clinicians optimize NICU practice to reduce the incidence of visual dysfunction in these children.

Risk and protective factors of intraventricular hemorrhage in preterm babies in Wuhan, China

OBJECTIVE

The aim of this study is to identify prenatal and perinatal risk and protective factors for the development of IVH, using a retrospective and case-control clinical study.

METHODS

Prenatal and perinatal data were collected from three NICUs between January 2010 and December 2010. Univariate analysis was performed between case and control groups, and multivariate analysis was done to find out risk and protective factors for development of IVH. Further analysis of these variables was undertaken for gestational age strata <30, 30-34, and 35-37 weeks.

RESULTS

By univariate analysis, factors related with IVH were C-section, prenatal steroid, pregnancy-induced hypertension, transport from other hospital, hypothermia, Apgar score at 1 and 5 min < 4, luminal, pathological jaundice, RDS, hypotension, volume expansion/inotropics, PO(2), repeat suctioning, and mechanical ventilation (P < 0.05). Five variables remained significant in multivariate analysis. C-section and prenatal steroid use were protective variables while mechanical ventilation, hypotension, and transport from other hospital were risk factors. Further analysis of these variables was undertaken for gestational age strata <30, 30-34, and 35-37 weeks. Prenatal steroid use remained significant as a protective variable in gestational age less than 35 weeks; hypotension was shown to be a risk factor just in the time period between 30-34 weeks; transport from other hospital was a risk factor in gestational age more than 30 weeks; mechanical ventilation remained non-significant during the gestational age strata studied.

CONCLUSION

In the present study, factors that related to neonatal IVH included hypotension, prenatal steroid use, and transportation.