Postnatal acetaminophen exposure and neurodevelopmental outcomes at 18-21 months corrected gestational age in preterm infants <29 weeks gestation: a retrospective cohort study

BACKGROUND

Studies have reported prenatal acetaminophen exposure is associated with abnormal neurodevelopment. There is limited and conflicting data on neurodevelopmental outcomes following postnatal acetaminophen exposure. Our objective was to investigate the neurodevelopmental outcomes of preterm infants < 29 weeks gestation postnatally exposed to acetaminophen.

METHODS

Retrospective cohort study of infants born between 2008 and 2017 at a tertiary care perinatal center. Exclusion criteria included chromosomal disorders, major congenital abnormalities, and congenital infections. The primary outcome was a composite score of <85 on the cognitive, language, or motor components of the Bayley Scales of Infant and Toddler Development, 3rd edition, assessed at 18 to 21 months corrected gestational age. Multivariate logistic regression was used to assess confounders.

RESULTS

Of the 945 infants included in the study, 120 were in the acetaminophen group. There was no difference in any of Bayley-III cognitive, language or motor composite scores of < 85 between the two groups for postnatal acetaminophen exposure, adjusted odds ratios (aORs) 1.03, 95% CI 0.60-1.78, or days of acetaminophen use, aORs 1.10, 95% CI 0.93-1.29.

CONCLUSIONS

There was no difference in neurodevelopmental outcome between the acetaminophen exposed and non-exposed groups. Our results need validation in larger cohorts.

IMPACT

Animal research and cohort studies have suggested that prenatal acetaminophen exposure may be associated with an elevated risk of neurobehavioral abnormalities. However, there is limited and conflicting research on the impact of postnatal acetaminophen on neurodevelopment. The results of this study suggest that postnatal acetaminophen does not negatively impact neurodevelopment at 18 to 21 months in preterm infants born at <29 weeks gestational age. While these results need validation in larger and more longitudinal studies, this study provides reassurance for the use of postnatal acetaminophen in extremely preterm infants.

Infants less than or equal to 2.5 kg have increased mortality and worse motor neurodevelopmental outcomes at 2 years of age after Norwood-Sano palliation

Objectives

In infants with single-ventricle congenital heart disease, prematurity and low weight at the time of the Norwood operation are risk factors for mortality. Reports assessing outcomes (including neurodevelopment) post Norwood palliation in infants ≤2.5 kg are limited.

Methods

All infants who underwent a Norwood-Sano procedure between 2004 and 2019 were identified. Infants ≤2.5 kg at the time of the operation (cases) were matched 3:1 with infants >3.0 kg (comparisons) for year of surgery and cardiac diagnosis. Demographic and perioperative characteristics, survival, and functional and neurodevelopmental outcomes were compared.

Results

Twenty-seven cases (mean ± standard deviation: weight 2.2 ± 0.3 kg and age 15.6 ± 14.1 days at surgery) and 81 comparisons (3.5 ± 0.4 kg and age 10.9 ± 7.9 days at surgery) were identified. Post-Norwood, cases had a longer time to lactate ≤2 mmol/L (33.1 ± 27.5 vs 17.9 ± 12.2 hours, P < .001), longer duration of ventilation (30.5 ± 24.5 vs 18.6 ± 17.5 days, P = .005), greater need for dialysis (48.1% vs 19.8%, P = .007), and greater need for extracorporeal membrane oxygenation support (29.6% vs 12.3%, P = .004). Cases had significantly greater postoperative (in-hospital) (25.9% vs 1.2%, P < .001) and 2-year (59.2% vs 11.1%, P < .001) mortality. Neurodevelopmental assessment showed the following for cases versus comparisons, respectively: cognitive delay (18.2% vs 7.9%, P = .272), language delay (18.2% vs 11.1%, P = .505), and motor delay (27.3% vs 14.3%, P = .013).

Conclusions

Infants ≤2.5 kg at Norwood-Sano palliation have significantly increased postoperative morbidity and mortality up to 2-year follow-up. Neurodevelopmental motor outcomes were worse in these infants. Additional studies are warranted to assess the outcome of alternative medical and interventional treatment plans in this patient population.

Parent-Integrated Interventions to Improve Language Development in Children Born Very Preterm

Neurodevelopmental challenges in children born very preterm are common and not improving. This study tested the feasibility of using Evidence-based Practice to Improve Quality (EPIQ), a proven quality improvement technique that incorporates scientific evidence to target improving language abilities in very preterm populations in 10 Canadian neonatal follow-up programs. Feasibility was defined as at least 70% of sites completing four intervention cycles and 75% of cycles meeting targeted aims. Systematic reviews were reviewed and performed, an online quality improvement educational tool was developed, multidisciplinary teams that included parents were created and trained, and sites provided virtual support to implement and audit locally at least four intervention cycles of approximately 6 months in duration. Eight of ten sites implemented at least four intervention cycles. Of the 48 cycles completed, audits showed 41 (85%) met their aim. Though COVID-19 was a barrier, parent involvement, champions, and institutional support facilitated success. EPIQ is a feasible quality improvement methodology to implement family-integrated evidence-informed interventions to support language interventions in neonatal follow-up programs. Further studies are required to identify potential benefits of service outcomes, patients, and families and to evaluate sustainability.

Alberta Collaborative Quality Improvement Strategies to Improve Outcomes of Moderate and Late Preterm Infants (ABC-QI) Trial: a protocol for a multicentre, stepped-wedge cluster randomized trial

BACKGROUND

Evidence-based Practice for Improving Quality (EPIQ) is a collaborative quality improvement method adopted by the Canadian Neonatal Network that led to decreased mortality and morbidity in very preterm neonates. The Alberta Collaborative Quality Improvement Strategies to Improve Outcomes of Moderate and Late Preterm Infants (ABC-QI) Trial aims to evaluate the impact of EPIQ collaborative quality improvement strategies in moderate and late preterm neonates in Alberta, Canada.

METHODS

In a 4-year, multicentre, stepped-wedge cluster randomized trial involving 12 neonatal intensive care units (NICUs), we will collect baseline data with the current practices in the first year (all NICUs in the control arm). Four NICUs will transition to the intervention arm at the end of each year, with 1 year of follow-up after the last group transitions to the intervention arm. Neonates born at 32 + 0 to 36 + 6 weeks' gestation with primary admission to NICUs or postpartum units will be included. The intervention includes implementation of respiratory and nutritional care bundles using EPIQ strategies, including quality improvement team building, quality improvement education, bundle implementation, quality improvement mentoring and collaborative networking. The primary outcome is length of hospital stay; secondary outcomes include health care costs and short-term clinical outcomes. Neonatal intensive care unit staff will complete a survey in the first year to assess quality improvement culture in each unit, and a sample will be interviewed 1 year after implementation in each unit to evaluate the implementation process.

INTERPRETATION

The ABC-QI Trial will assess whether collaborative quality improvement strategies affect length of stay in moderate and late preterm neonates. It will provide detailed population-based data to support future research, benchmarking and quality improvement.

TRIAL REGISTRATION

ClinicalTrials.gov, no. NCT05231200.

Le suivi de l'extrême prématuré après le congé des soins intensifs néonatals

La survie des extrêmes prématurés (moins de 28 semaines d'âge gestationnel) s'est améliorée au fil du temps. Bon nombre s'en sortent bien et ont une bonne qualité de vie. Ils demeurent toutefois vulnérables à des problèmes de santé, y compris des difficultés neurosensorielles et neurodéveloppementales, que les médecins de première ligne, les pédiatres et les cliniques spécialisées doivent surveiller. Le présent document de principes passe en revue les conséquences médicales et neurodéveloppementales potentielles pour les extrêmes prématurés dans les deux ans suivant leur congé et fournit des stratégies de counseling, de dépistage précoce et d'intervention. Parce qu'ils sont tous liés à l'extrême prématurité, la dysplasie bronchopulmonaire ou les troubles respiratoires, les problèmes d'alimentation et de croissance, le développement neurosensoriel (vision et audition), la paralysie cérébrale et le trouble du spectre de l'autisme doivent faire rapidement l'objet d'une évaluation. Pour évaluer la croissance et le développement, il faut corriger l'âge chronologique en fonction de l'âge gestationnel jusqu'à 36 mois de vie. Par ailleurs, l'attention au bien-être émotionnel des parents et des proches fait partie intégrante des soins de qualité de l'extrême prématuré.

Follow-up care of the extremely preterm infant after discharge from the neonatal intensive care unit

The survival of babies born extremely preterm (EP, <28 weeks gestation) has improved over time, and many have good outcomes and quality of life. They remain at risk for health issues, including neurosensory and neurodevelopmental difficulties requiring monitoring by primary physicians, paediatricians, and specialty clinics. This statement reviews potential medical and neurodevelopmental consequences for EP infants in the first 2 years after discharge and provides strategies for counselling, early detection, and intervention. EP-related conditions to assess for early include bronchopulmonary dysplasia or respiratory morbidity, feeding and growth concerns, neurosensory development (vision and hearing), cerebral palsy, and autism spectrum disorder. Correction for gestational age should be used for growth and development until 36 months of age. Integral to quality care of the child born EP is attention to the emotional well-being of parents and caregivers.

Maternal High-Dose DHA Supplementation and Neurodevelopment at 18-22 Months of Preterm Children

OBJECTIVES

To determine whether maternal supplementation with high-dose docosahexaenoic acid (DHA) in breastfed, very preterm neonates improves neurodevelopmental outcomes at 18 to 22 months' corrected age (CA).

METHODS

Planned follow-up of a randomized, double-blind, placebo-controlled, multicenter trial to compare neurodevelopmental outcomes in breastfed, preterm neonates born before 29 weeks' gestational age (GA). Lactating mothers were randomized to receive either DHA-rich algae oil or a placebo within 72 hours of delivery until 36 weeks' postmenstrual age. Neurodevelopmental outcomes were assessed with the Bayley Scales of Infant and Toddler Development third edition (Bayley-III) at 18 to 22 months' CA. Planned subgroup analyses were conducted for GA (<27 vs ≥27 weeks' gestation) and sex.

RESULTS

Among the 528 children enrolled, 457 (86.6%) had outcomes available at 18 to 22 months' CA (DHA, N = 234, placebo, N = 223). The mean differences in Bayley-III between children in the DHA and placebo groups were -0.07 (95% confidence interval [CI] -3.23 to 3.10, P = .97) for cognitive score, 2.36 (95% CI -1.14 to 5.87, P = .19) for language score, and 1.10 (95% CI -2.01 to 4.20, P = .49) for motor score. The association between treatment and the Bayley-III language score was modified by GA at birth (interaction P = .07). Neonates born <27 weeks' gestation exposed to DHA performed better on the Bayley-III language score, compared with the placebo group (mean difference 5.06, 95% CI 0.08-10.03, P = .05). There was no interaction between treatment group and sex.

CONCLUSIONS

Maternal DHA supplementation did not improve neurodevelopmental outcomes at 18 to 22 months' CA in breastfed, preterm neonates, but subgroup analyses suggested a potential benefit for language in preterm neonates born before 27 weeks' GA.

Neurodevelopmental outcomes of preterm infants conceived by assisted reproductive technology

BACKGROUND

There have been concerns about the development of children conceived through assisted reproductive technology. Despite multiple studies investigating the outcomes of assisted conception, data focusing specifically on the neurodevelopmental outcomes of infants conceived through assisted reproductive technology and born preterm are limited.

OBJECTIVE

This study aimed to evaluate and compare the neurodevelopmental outcomes of preterm infants born at <29 weeks' gestation at 18 to 24 months' corrected age who were conceived through assisted reproductive technology and those who were conceived naturally.

STUDY DESIGN

This retrospective cohort study included inborn, nonanomalous infants, born at <29 weeks' gestation between January 1, 2010, and December 31, 2016, who had a neurodevelopmental assessment at 18 to 24 months' corrected age at any of the 10 Canadian Neonatal Follow-Up Network clinics. The primary outcome was neurodevelopmental impairment at 18 to 24 months, defined as the presence of any of the following: cerebral palsy; Bayley-III cognitive, motor, or language composite score of <85; sensorineural or mixed hearing loss; and unilateral or bilateral visual impairment. Secondary outcomes included mortality, composite of mortality or neurodevelopmental impairment, significant neurodevelopmental impairment, and each component of the primary outcome. We compared outcomes between infants conceived through assisted reproductive technology and those conceived naturally, using bivariate and multivariable analyses after adjustment.

RESULTS

Of the 4863 eligible neonates, 651 (13.4%) were conceived using assisted reproductive technology. Maternal age; education level; and rates of diabetes mellitus, receipt of antenatal corticosteroids, and cesarean delivery were higher in the assisted reproduction group than the natural conception group. Neonatal morbidity and death rates were similar except for intraventricular hemorrhage, which was lower in the assisted reproduction group (33% [181 of 546] vs 39% [1284 of 3318]; P=.01). Of the 4176 surviving infants, 3386 (81%) had a follow-up outcome at 18 to 24 months' corrected age. Multivariable logistic regression adjusting for gestational age, antenatal steroids, sex, small for gestational age, multiple gestations, mode of delivery, maternal age, maternal education, pregnancy-induced hypertension, maternal diabetes mellitus, and smoking showed that infants conceived through assisted reproduction was associated with lower odds of neurodevelopmental impairment (adjusted odds ratio, 0.67; 95% confidence interval, 0.52-0.86) and the composite of death or neurodevelopmental impairment (adjusted odds ratio, 0.67; 95% confidence interval, 0.54-0.84). Conception through assisted reproductive technology was associated with decreased odds of a Bayley-III composite cognitive score of <85 (adjusted odds ratio, 0.68; 95% confidence interval, 0.48-0.99) and composite language score of <85 (adjusted odds ratio, 0.67; 95% confidence interval, 0.50-0.88).

CONCLUSION

Compared with natural conception, assisted conception was associated with lower odds of adverse neurodevelopmental outcomes, especially cognitive and language outcomes, at 18 to 24 months' corrected age among preterm infants born at <29 weeks' gestation. Long-term follow-up studies are required to assess the risks of learning disabilities and development of complex visual-spatial and processing skills in these children as they reach school age.

Does a Split-Week Gestational Age Model Provide Valuable Information on Neurodevelopmental Outcomes in Extremely Preterm Infants?

Our primary objective for this follow-up study was to compare the neurodevelopmental outcomes of a surviving cohort of infants using a split-week gestational model (early versus late) gestational age (GA) and the standard completed GA categorization. Neurodevelopmental outcomes using a split-week GA model defined as early (X, 0–3) and late (X, 4–6), with X being 23–26 weeks GA, were compared to outcomes using completed weeks GA. In total, 1012 infants were included in the study. Statistically significant differences were noted in outcomes between the early and late split of the gestational week at 23 weeks (early vs. late), with 13.3% vs. 54.5% for no neurodevelopmental impairment, and 53.3% vs. 22.7% for significant impairment (p = 0.034), respectively. There were no differences seen in the split week model for 24, 25, and 26 weeks. A trend towards improved neurodevelopmental outcomes was seen with each increasing gestation week. The split-week model did not provide additional information for pregnancies and infants between 24 and 26 weeks gestation. It did, however, provide information for counsel for infants at 23 weeks gestation, showing benefits in the late versus early half of the week.

Les inhibiteurs sélectifs de la recapture de la sérotonine ou de la sérotonine et de la noradrénaline pendant la grossesse : les effets cliniques chez les nourrissons et les enfants

Le présent document de principes fournit des conseils sur la surveillance, les soins et le suivi des nouveau-nés exposés in utero à des inhibiteurs sélectifs de la recapture de la sérotonine ou de la sérotonine et de la noradrénaline. La dépression et l’anxiété sont courantes pendant la grossesse et la période postnatale. Bien qu’il y ait des risques à prendre des médicaments pendant la grossesse, la dépression et l’anxiété non traitées ou traitées insuffisamment comportent aussi des risques pour le nouveau-né. Le tiers des nouveau-nés exposés in utero à des inhibiteurs sélectifs de la recapture de la sérotonine ou de la sérotonine et de la noradrénaline présente un syndrome d’inadaptation néonatale, mais il est généralement léger et autorésolutif. Les faibles taux de ces médicaments excrétés dans le lait maternel n’empêchent pas l’allaitement. Dans de rares cas, l’hypertension artérielle pulmonaire persistante du nouveau-né et les cardiopathies congénitales sont associées à l’exposition à ces médicaments in utero. Les publications scientifiques ne s’entendent pas toutes sur l’évolution neurodéveloppementale de ces enfants, notamment pour ce qui est du trouble du spectre de l’autisme et du trouble de déficit de l’attention/hyperactivité. Ces incohérences découlent probablement d’autres facteurs (génétique, dépression de la mère, mode de vie, autres problèmes de santé), plutôt que de l’exposition in utero à des inhibiteurs sélectifs de la recapture de la sérotonine ou de la sérotonine et de la noradrénaline. Les professionnels de la santé et les parents devraient être rassurés : en général, des mesures non pharmacologiques suffisent pour traiter le syndrome d’inadaptation néonatale, et le risque de graves effets indésirables découlant de l’exposition à ces médicaments in utero est faible.

Selective serotonin reuptake inhibitors or serotonin-norepinephrine reuptake inhibitors in pregnancy: Infant and childhood outcomes

This position statement provides guidance for the monitoring, care, and follow-up of newborns exposed to selective serotonin reuptake inhibitors (SSRIs) or serotonin-norepinephrine reuptake inhibitors (SNRIs) in utero. Depression and anxiety are common during pregnancy and postpartum. While there are risks to taking medications during pregnancy, untreated or incompletely managed depression and anxiety also carry risks for the newborn. Poor neonatal adaptation syndrome (PNAS) occurs in one-third of newborns exposed to SSRIs or SNRIs in utero, and is generally mild and self-limiting. The low levels of SSRIs and SNRIs excreted in breast milk are compatible with breastfeeding. Persistent pulmonary hypertension of the newborn and congenital heart defects are rare associations of exposure to SSRIs or SNRIs in utero. There are inconsistencies in the literature regarding neurodevelopmental outcomes, specifically autism spectrum disorder and attention-deficit hyperactivity disorder. The inconsistencies likely relate to other factors (i.e., genetics, maternal depression, lifestyle, and comorbidities), rather than exposure to SSRIs or SNRIs in utero. Health care providers and parents should be reassured that PNAS is generally treatable with nonpharmacological measures, and that the risk of serious adverse effects from exposure to SSRIs or SNRIs in utero is low.

Split-week gestational age model provides valuable information on outcomes in extremely preterm infants

AIM

To compare composite outcomes of neonatal mortality or morbidity using a split-week gestational age (GA) model to completed weeks GA maturity at 23-26 weeks gestation.

METHODS

This was a retrospective cohort study of infants born at 23-26 weeks GA. Outcomes using a split-week GA model defined as early (X, 0-3) and late (X, 4-6) with X being 23-26 weeks GA were compared to outcomes using completed weeks GA, with a similar comparison between the late split of the preceding week (X, 4-6) and early split of the subsequent week (X + 1, 0-3).

RESULTS

A total of 1345 infants were included in the study. Statistically significant differences were noted in outcomes between the early and late split of the gestational week at 24 (early vs late, 85.6% vs 73.0%), 25 (69.6% vs 56.6%) and 26 weeks (55.9% vs 37.4%), but not at 23 weeks GA (95.2% vs 94.5%). No statistically significant differences were noted between the late vs early part of the subsequent week (23, 4-6) vs (24, 0-3), and (24, 4-6) vs (25, 0-3) GA.

CONCLUSION

Neonatal outcome estimates using a split week model differs from that based on the use of completed weeks of gestational maturity.

Supporting and communicating with families experiencing a perinatal loss

Perinatal loss is one of the most devastating events a family can experience. This practice point focuses on circumstances that are likely to involve paediatric health care professionals. Recommendations are provided for compassionate communication, bereavement, sibling care and counselling to support families.

Severe Neurodevelopmental Impairment in Neonates Born Preterm: Impact of Varying Definitions in a Canadian Cohort

OBJECTIVE

To assess the impact of variations in the definition of severe neurodevelopmental impairment (NDI) on the incidence of severe NDI and the association with risk factors using the Canadian Neonatal Follow-Up Network cohort.

STUDY DESIGN

Literature review of severe NDI definitions and application of these definitions were performed in this database cohort study. Infants born at 23-28 completed weeks of gestation between 2009 and 2011 (n = 2187) admitted to a Canadian Neonatal Network neonatal intensive care unit and assessed at 21 months' corrected age were included. The incidence of severe NDI, aORs, and 95% CIs were calculated to express the relationship between risk factors and severe NDI using the definitions with the highest and the lowest incidence rates of severe NDI.

RESULTS

The incidence of severe NDI ranged from 3.5% to 14.9% (highest vs lowest rate ratio 4.29; 95% CI 3.37-5.47). The associations between risk factors and severe NDI varied depending on the definition used. Maternal ethnicity, employment status, antenatal corticosteroid treatment, and gestational age were not associated consistently with severe NDI. Although maternal substance use, sex, score of neonatal acute physiology >20, late-onset sepsis, bronchopulmonary dysplasia, and brain injury were consistently associated with severe NDI irrespective of definition, the strength of the associations varied.

CONCLUSIONS

The definition of severe NDI significantly influences the incidence and the associations between risk factors and severe NDI. A standardized definition would facilitate site comparisons and scientific communication.

DOES PRETERM INFANTS BORN OUTSIDE TERTIARY PERINATAL CENTRE HAVE AN IMPACT ON NEURODEVELOPMENTAL AND GROWTH OUTCOME AT 36 MONTHS CORRECTED AGE?

BACKGROUND

Infants born in tertiary perinatal centres (inborn) have higher survival and lower morbidity than outborn infants. However, there is limited information regarding the long term neurodevelopmental and growth outcomes among outborn preterm infants.

OBJECTIVES

To compare the neurodevelopmental and growth outcomes at 36 months corrected age (CA) between outborn and inborn infants born < 29 weeks.

DESIGN/METHODS

This is a retrospective cohort study. We included infants born <29 weeks admitted to Foothills Medical Centre, Calgary between January 2000 and December 2012, who had neurodevelopmental(ND) assessment up to 36 months CA. Infants with intrauterine infection, major congenital and chromosomal anomalies were excluded. Our primary outcome was composite of death or neurodevelopmental impairment (NDI). We compared ND and growth outcomes between inborn and the outborn infants using univariate and multivariate logistic regression analysis.

RESULTS

Of 1235 eligible infants, 175 (14%) were outborn. Outborn infants were lower in GA (25.8 ± 1.7 wk vs 26.2 ± 1.5 wk), had lower chorioamnionitis rate (15% vs 24%), received less antenatal steroid (55% vs 90%) and maternal antibiotics (51% vs 68%). Neonatal morbidities were similar between the two groups except that outborn infants had higher rates of severe brain injury (24% vs 12%) and mortality (22% vs 11%).

Of 1078 eligible survivors, 1048 (97%) were followed. There was no difference in ND outcomes (Table). Multivariate regression analysis controlling for potential confounders (GA, gender, chorioamnionitis, antenatal steroids and maternal age) showed outborn status was not associated with composite primary outcome of death or ND impairment (adjusted OR: 1.09, 95% CI, 0.69, 1.70). Growth outcomes were not significantly different between two groups.

CONCLUSION

In this cohort, neurodevelopmental and growth outcomes does not appear to be significantly different between outborn and infants at 36 months corrected age.

Neurodevelopmental Outcomes of Infants Born at <29 Weeks of Gestation Admitted to Canadian Neonatal Intensive Care Units Based on Location of Birth

OBJECTIVE

To compare mortality and neurodevelopmental outcomes of outborn and inborn preterm infants born at <29 weeks of gestation admitted to Canadian neonatal intensive care units (NICUs).

STUDY DESIGN

Data were obtained from the Canadian Neonatal Network and Canadian Neonatal Follow-up Network databases for infants born at <29 weeks of gestation admitted to NICUs from April 2009 to September 2011. Rates of death, severe neurodevelopmental impairment (NDI), and overall NDI were compared between outborn and inborn infants at 18-21 months of age, corrected for prematurity.

RESULTS

Of 2951 eligible infants, 473 (16%) were outborn. Mean birth weight (940 ± 278 g vs 897 + 237 g), rates of treatment with antenatal steroids (53.9% vs 92.9%), birth weight small for gestational age (5.3% vs 9.4%), and maternal college education (43.7% vs 53.9%) differed between outborn and inborn infants, respectively (all P values <.01). The median Score for Neonatal Acute Physiology-II (P = .01) and Apgar score at 5 minutes (P < .01) were higher in inborn infants. Severe brain injury was more common among outborn infants (25.3% vs 14.7%, P < .01). Outborn infants had higher odds of death or severe NDI (aOR 1.7, 95% CI 1.3-2.2), death or overall NDI (aOR 1.6, 95% CI 1.2-2.2), death (aOR 2.1, 95% CI 1.5-3.0), and cerebral palsy (aOR 1.9, 95% CI 1.1-3.3).

CONCLUSIONS

The composite outcomes of death or neurodevelopmental impairment were significantly higher in outborn compared with inborn infants admitted to Canadian NICUs. Adverse outcomes were mainly attributed to increased mortality and cerebral palsy in outborn neonates.

Establishing Bayley-III cut-off scores at 21 months for predicting low IQ scores at 3 years of age in a preterm cohort

Objective

To evaluate predictive validity and establish cut-off scores on the Bayley-III at age 21 months that best predict Intelligence Quotient (IQ) scores <70 or <80) at 3 years in a high-risk preterm cohort.

Method

Bayley-III evaluations at 21 months corrected age and intellectual assessments, primarily with the WPPSI-III, at 3 years corrected age were conducted with 520 infants born less than 29 weeks gestational age or less than 1250 g birth weight. Receiver Operator Characteristic (ROC) curves were used to establish Bayley-III Cognitive Composite cut-off scores that maximized Sensitivity and Specificity in predicting low IQ. Similar analyses were performed using the Language Composite, and a research derived mean Cognitive-Language Composite.

Results

A regression model for the association between 21-month Bayley-III Cognitive Composite and 3-year IQ scores was significant (P<0.0001, Adjusted R²=0.36). The ROC area under the Curve was 0.90 for the Cognitive Composite predicting IQ<70. The cut-off score that maximized Sensitivity and Specificity for predicting 3-year IQ<70 was a Cognitive Composite of <80. The ROC Area under the Curve was 0.80 for Cognitive Composites predicting IQ<80 and a Cognitive Composite cut-off score of <90 maximized Sensitivity and Specificity.

Conclusion

In this high-risk preterm cohort, there was a strong association between the Bayley-III Cognitive Composite at 21 months and IQ at 3 years. A Cognitive Composite cut-off score of <80 optimized classification of IQ<70 at 3 years, and a Cognitive Composite cut-off score of <90 optimized classification of IQ<80.

Altered breathing mechanics and ventilatory response during exercise in children born extremely preterm

Background

Extreme preterm birth confers risk of long-term impairments in lung function and exercise capacity. There are limited data on the factors contributing to exercise limitation following extreme preterm birth. This study examined respiratory mechanics and ventilatory response during exercise in a large cohort of children born extremely preterm (EP).

Methods

This cohort study included children 8–12 years of age who were born EP (≤28 weeks gestation) between 1997 and 2004 and treated in a large regionalised neonatal intensive care unit in western Canada. EP children were divided into no/mild bronchopulmonary dysplasia (BPD) (ie, supplementary oxygen or ventilation ceased before 36 weeks gestational age; n=53) and moderate/severe BPD (ie, continued supplementary oxygen or ventilation at 36 weeks gestational age; n=50). Age-matched control children (n=65) were born at full term. All children attempted lung function and cardiopulmonary exercise testing measurements.

Results

Compared with control children, EP children had lower airway flows and diffusion capacity but preserved total lung capacity. Children with moderate/severe BPD had evidence of gas trapping relative to other groups. The mean difference in exercise capacity (as measured by oxygen uptake (VO₂)% predicted) in children with moderate/severe BPD was −18±5% and −14±5.0% below children with no/mild BPD and control children, respectively. Children with moderate/severe BPD demonstrated a potentiated ventilatory response and greater prevalence of expiratory flow limitation during exercise compared with other groups. Resting lung function did not correlate with exercise capacity.

Conclusions

Expiratory flow limitation and an exaggerated ventilatory response contribute to respiratory limitation to exercise in children born EP with moderate/severe BPD.

Connection versus disconnection: examining culturally competent care in the neonatal intensive care unit

Culturally competent health care is of critical importance; however, it is presented as a frequent challenge in health care settings. This study explored cross-cultural care from the health care provider perspective within two tertiary level Neonatal Intensive Care Units (NICUs). Fifty eight inter-professional health care providers (HCP) participated in focus groups. Participants identified perceived care-related experiences of newly immigrated parents whose infant received care in the NICU as well as health care provider perspectives on delivering that care. Results identified core processes of "connection" and "disconnection," which appeared to have a substantial bearing on NICU experience and interaction. Connection comprised congruity, synergy, and "fit," and resulted in an enhanced relationship between the family and HCP. Disconnection, in contrast, entailed a lack of "fit" and in some cases, misunderstanding and/or conflict between the family and a member or members of the health care team. Connection and disconnection occurred at various junctures of NICU care. These junctures reflected interaction between the family and HCP at the bedside and/or at the level of the unit, hospital, or community at large. Implications for practice, policy, and research are discussed.

Early childhood outcomes of infants born with gastroschisis

PURPOSE

To describe neonatal and childhood outcomes of a contemporary cohort of infants with gastroschisis.

METHODS

Observational, single center, inception cohort of children born with gastroschisis from January 2005 to December 2008.

RESULTS

Of 63 infants, 61 survived to hospital discharge and 39 were seen for follow-up. Complications included sepsis (37%), necrotizing enterocolitis (10%), parenteral nutrition related cholestasis (25%), and short bowel syndrome (13%). Of survivors, 5% had visual impairment and 10% had hearing loss. No child tested had mental delay or cerebral palsy. Early gestational age predicted death or disability (OR 0.60, 95% CI 0.38, 0.96; p=0.033). There was a high incidence of prescription medications for presumed gastroesophageal reflux (90%). Some infants continued to require tube feeds (15%). There were improvements in longitudinal growth reflected in increasing z-scores.

CONCLUSIONS

Although children with gastroschisis are at risk for disability, childhood outcomes are encouraging.

Neonatal and neurodevelopmental outcomes of very low birth weight infants with histologic chorioamnionitis

OBJECTIVE

To determine survival and neurodevelopmental outcomes at 18 months corrected age among very low birth weight infants ≤ 32 weeks gestation with histologic chorioamnionitis.

STUDY DESIGN

Observational, regionalized, single-center cohort study with prospective follow-up.

RESULTS

Of the 628 infants meeting the selection criteria, 303 (48%) were born to mothers with evidence of histologic chorioamnonitis. Neonates with histologic chorioamnonitis were of lower gestational age and birth weight. On univariate analysis, they were more likely to have hypotension, bronchopulmonary dysplasia, severe intraventricular hemorrhage, severe retinopathy of prematurity, early-onset sepsis, and death. Infants with histologic chorioamnonitis were more likely to have any neurodevelopmental impairment, specifically, mental delay with a lower mental developmental index. When adjusting for perinatal variables, histologic chorioamnonitis had a protective effect on mortality rates (adjusted OR = 0.44, 95% CI: 0.24-0.8; P = .01; n = 619), had a nonsignificant effect on neurodevelopmental impairment (adjusted odds ratio = 1.33, 95% CI: 0.82-2.17; P = .25; n = 496), and was associated with a 4-point lower mental developmental index at 18-months follow-up (adjusted difference -3.93, 95% CI: -7.52 to -0.33; P = .03; n = 496).

CONCLUSIONS

Although infants with histologic chorioamnonitis were at an increased risk for death and neurodevelopmental impairment, after multivariate analyses, histologic chorioamnonitis was not associated with adverse long-term outcomes. Results suggest fetal protection from treatment-responsive maternal infection and inflammation.

Improvement of short- and long-term outcomes for very low birth weight infants: Edmonton NIDCAP trial

OBJECTIVE

Our objective was to determine the impact of Newborn Individualized Developmental Care and Assessment Program (NIDCAP)-based care on length of stay of very low birth weight (VLBW) infants. Secondary outcome measures were days of ventilation, incidence of chronic lung disease, and 18-month neurodevelopmental outcomes.

METHODS

This cluster-randomized, controlled trial took place in a large NICU in Canada, with follow-up evaluation at 18 months of age, from September 1999 to September 2004. One hundred VLBW singleton infants and 10 VLBW twin sets were assigned randomly to NIDCAP-based or control care, and 90% participated in follow-up assessments. The intervention was NIDCAP-based care (N = 56), that is, care by NIDCAP-educated staff members and behavioral observations. The control group (N = 55) received standard NICU care. Statistical analyses were adjusted for cluster randomization. Although the intervention was not blinded, the pediatricians making the decisions to discharge the infants were not involved in the study, and the follow-up staff members were blinded with respect to group.

RESULTS

NIDCAP group infants had reduced length of stay (median: NIDCAP: 74 days; control: 84 days; P = .003) and incidence of chronic lung disease (NIDCAP: 29%; control: 49%; odds ratio: 0.42 [95% confidence interval: 0.18-0.95]; P = .035). At 18 months of adjusted age, NIDCAP group infants had less disability, specifically mental delay (NIDCAP: 10%; control: 30%; odds ratio: 0.25 [95% confidence interval: 0.08-0.82]; P = .017).

CONCLUSION

NIDCAP-based care for VLBW infants improved short- and long-term outcomes significantly.

Persistent pulmonary hypertension of the newborn presenting as the primary manifestation of intracranial arteriovenous malformation of the Vein of Galen

Arteriovenous malformations of the Vein of Galen continue to present diagnostic and therapeutic challenges in the neonatal period. Approximately 40-50% of all malformations of the Vein of Galen present in the neonatal period, usually with congestive heart failure. These neonates represent the most severe cases and are also the most difficult to manage. We report a case of a neonate with a Vein of Galen Malformation who presented with cyanosis, a cardiac murmur, and severe persistent pulmonary hypertension of the newborn. Cardiac failure developed later in the patient's course. The degree of pulmonary hypertension on echocardiography was used to time endovascular embolization of the Vein of Galen Malformation. Following embolization, his pulmonary hypertension subsided dramatically. We speculate that pulmonary hypertension associated with Vein of Galen Malformations has been underestimated in the morbidity and demise of these neonates, and should be more aggressively monitored and treated.