Identifying effect modifiers of systemic hydrocortisone treatment initiated 7-14 days after birth in ventilated very preterm infants on long-term outcome: secondary analysis of a randomised controlled trial

OBJECTIVE

To explore clinical effect modifiers of systemic hydrocortisone in ventilated very preterm infants for survival and neurodevelopmental outcome at 2 years' corrected age (CA).

DESIGN

Secondary analysis of a randomised placebo-controlled trial.

SETTING

Dutch and Belgian neonatal intensive care units.

PATIENTS

Infants born <30 weeks' gestational age (GA), ventilator-dependent in the second week of postnatal life.

INTERVENTION

Infants were randomly assigned to systemic hydrocortisone (cumulative dose 72.5 mg/kg; n=182) or placebo (n=190).

MAIN OUTCOME MEASURES

The composite of death or neurodevelopmental impairment (NDI) at 2 years' CA and its components. Candidate effect modifiers (GA, small for GA, respiratory index, sex, multiple births, risk of moderate/severe bronchopulmonary dysplasia or death) were analysed using regression models with interaction terms and subpopulation treatment effect pattern plots.

RESULTS

The composite outcome was available in 356 (96.0%) of 371 patients (one consent withdrawn). For this outcome, treatment effect heterogeneity was seen across GA subgroups (<27 weeks: hydrocortisone (n=141) vs placebo (n=156), 54.6% vs 66.2%; OR 0.61 (95% CI 0.38 to 0.98); ≥27 weeks: hydrocortisone (n=30) vs placebo (n=31), 66.7% vs 45.2%; OR 2.43 (95% CI 0.86 to 6.85); p=0.02 for interaction). This effect was also found for the component death (<27 weeks: 20.1% vs 32.1%; OR 0.53 (95% CI 0.32 to 0.90); ≥27 weeks: 28.1% vs 16.1%; OR 2.04 (95% CI 0.60 to 6.95); p=0.049 for interaction) but not for the component NDI. No differential treatment effects were observed across other subgroups.

CONCLUSION

This secondary analysis suggests that in infants <27 weeks' GA, systemic hydrocortisone may improve the outcome death or NDI, mainly driven by its component death. There was insufficient evidence for other selected candidate effect modifiers.

Effect of systemic hydrocortisone in ventilated preterm infants on parent-reported behavioural outcomes at 2 years' corrected age: follow-up of a randomised clinical trial

OBJECTIVE

To report the parent-reported behavioural outcomes of infants included in the Systemic Hydrocortisone To Prevent Bronchopulmonary Dysplasia in preterm infants study at 2 years' corrected age (CA).

DESIGN

Randomised placebo-controlled trial.

SETTING

Dutch and Belgian neonatal intensive care units.

PATIENTS

Infants born <30 weeks' gestation and/or birth weight <1250 g, and ventilator dependent in the second week of life.

INTERVENTION

Infants were randomly assigned to a 22-day course of systemic hydrocortisone (cumulative dose 72.5 mg/kg; n=182) or placebo (n=190).

MAIN OUTCOME MEASURES

Parent-reported behavioural outcomes at 2 years' CA assessed with the Child Behavior Checklist (CBCL 1½-5).

RESULTS

Parents completed the CBCL of 183 (70% (183/262)) infants (hydrocortisone group, n=96; placebo group, n=87). Multiple imputation was used to account for missing data. Infants with critically elevated T-scores (>55) were found in 22.9%, 19.1% and 29.4% of infants for total, internalising and externalising problems, respectively; these scores were not significantly different between groups (mean difference -1.52 (95% CI -4.00 to 0.96), -2.40 (95% CI -4.99 to 0.20) and -0.81 (95% CI -3.40 to 1.77), respectively). In the subscales, we found a significantly lower T-score for anxiety problems in the hydrocortisone group (mean difference -1.26, 95% CI -2.41 to -0.12).

CONCLUSION

This study found high rates of behaviour problems at 2 years' CA following very preterm birth, but these problems were not associated with hydrocortisone treatment initiated between 7 and 14 days after birth in ventilated preterm infants.

TRIAL REGISTRATION NUMBER

NTR2768; EudraCT 2010-023777-19.

[Two-year follow-up of infants born at 24 weeks gestation; first outcomes following implementation of the new 'Guideline for perinatal policy in cases of extreme prematurity']

OBJECTIVE

Since 2010 the guideline 'Guideline for perinatal policy in cases of extreme prematurity' has advised an active policy in infants born at 24 weeks gestation. We investigated how infants born at 24 and 25 weeks gestation in the first year following the implementation of the guideline had developed by the age of 2 years.

DESIGN

Retrospective national cohort study.

METHOD

The study population consisted of all surviving infants born in the Netherlands at 24 or 25 weeks gestation in the period from 1 October 2010 to 1 October 2011. At a corrected age of 2 years the children underwent a general physical and neurological examination, and their cognitive scores were determined on the 'Bayley scales of infant and toddler development' (Bayley III). Examinations took place in the 10 neonatal intensive care units (NICU's) in the Netherlands.

RESULTS

Of 185 extremely premature infants, 166 were admitted to a NICU. A total of 95 survived to a corrected age of 2 years; 78 (82%) children were examined. Their average cognitive score on the Bayley III scale was 88 (SD: 16). Among the children born at 24 weeks gestation, 20% had mild disabilities and 20% had moderate to severe disabilities. Among the children born at 25 weeks gestation, 17% had mild disabilities and 12% had moderate to severe disabilities.

CONCLUSION

Of the children born at 24 weeks gestation in the first year after the introduction of active policy in the Netherlands and surviving to 2 years of age (46%), more than half had developed without disabilities. This was comparable to children born at 25 weeks gestation. Of all children born at 24 weeks gestation, 25% survived to 2 years of age without disabilities.

Improving Reliability of Monitoring Background EEG Dynamics in Asphyxiated Infants

The goal of this study is to develop an automated algorithm to quantify background electroencephalography (EEG) dynamics in term neonates with hypoxic ischemic encephalopathy. The recorded EEG signal is adaptively segmented and the segments with low amplitudes are detected. Next, depending on the spatial distribution of the low-amplitude segments, the first part of the algorithm detects (dynamic) interburst intervals (dIBIs) and performs well on the relatively artifact-free EEG periods and well-defined burst-suppression EEG periods. However, on testing the algorithm on EEG recordings of more than 48 h per neonate, a significant number of misclassified and dubious detections were encountered. Therefore, as the next step, we applied machine learning classifiers to differentiate between definite dIBI detections and misclassified ones. The developed algorithm achieved a true positive detection rate of 98%, 97%, 88%, and 95% for four duration-related dIBI groups that we subsequently defined. We benchmarked our algorithm with an expert diagnostic interpretation of EEG periods (1 h long) and demonstrated its effectiveness in clinical practice. We show that the detection algorithm effectively discriminates challenging cases encountered within mild and moderate background abnormalities. The dIBI detection algorithm improves identification of neonates with good clinical outcome as compared to the classification based on the classical burst-suppression interburst interval.

The Ages and Stages Questionnaire and Neurodevelopmental Impairment in Two-Year-Old Preterm-Born Children

Objective

To test the ability of the Ages and Stages Questionnaire, Third Edition (ASQ3) to help identify or exclude neurodevelopmental impairment (NDI) in very preterm-born children at the corrected age of two.

Methods

We studied the test results of 224 children, born at <32 postmenstrual weeks, who had scores on ASQ3 and Bayley Scales of Infant and Toddler Development, Third Edition (BSIDIII) and neurological examination at 22–26 months’ corrected age. We defined NDI as a score of <70 on the cognitive—or motor composite scale of BSIDIII, or impairment on neurological examination or audiovisual screening. We compared NDI with abnormal ASQ3 scores, i.e., < -2SDs on any domain, and with ASQ3 total scores. To correct for possible overestimation of BSIDIII, we also analyzed the adjusted BSIDIII thresholds for NDI, i.e., scores <80 and <85.

Results

We found 61 (27%) children with abnormal ASQ3 scores, and 10 (4.5%) children who had NDI with original BSIDIII thresholds (<70). Twelve children had NDI at BSIDIII thresholds at <80, and 15 had <85. None of the 163 (73%) children who passed ASQ3 had NDI. The sensitivity of ASQ3 to detect NDI was excellent (100%), its specificity was acceptable (76%), and its negative predictive value (NPV) was 100%. Sensitivity and NPV remained high with the adjusted BSIDIII thresholds.

Conclusion

The Ages and Stages Questionnaire is a simple, valid and cost-effective screening tool to help identify and exclude NDI in very preterm-born children at the corrected age of two years.

The puzzle of apparent life-threatening events in a healthy newborn

Apneic neonatal seizures can present as apparent life-threatening events. We report a newborn with unexplained episodes of apnea associated with cyanosis and desaturation, starting on the first day postpartum. Biochemical tests were normal. Central nervous system infections as well as abnormalities of upper airways and cardiovascular system were excluded. Brain monitoring using amplitude-integrated electroencephalography (aEEG) was inconclusive. Continuous monitoring using video EEG revealed epileptic seizures originating from the left temporal region as the cause of the apneas. Magnetic resonance imaging (MRI) of the brain showed a developmental malformation of the left frontal and temporal lobes. The patient became seizure free after treatment with antiepileptic medication. This report illustrates that brain monitoring using amplitude-integrated EEG alone could miss focal neonatal seizures. When clinical suspicion of apneic seizures is high in infants with apparent life threatening events, multichannel polygraphic video-EEG monitoring is indicated. Prompt diagnosis and treatment can be life saving.

Relationship of EEG sources of neonatal seizures to acute perinatal brain lesions seen on MRI: a pilot study

Even though it is known that neonatal seizures are associated with acute brain lesions, the relationship of electroencephalographic (EEG) seizures to acute perinatal brain lesions visible on magnetic resonance imaging (MRI) has not been objectively studied. EEG source localization is successfully used for this purpose in adults, but it has not been sufficiently explored in neonates. Therefore, we developed an integrated method for ictal EEG dipole source localization based on a realistic head model to investigate the utility of EEG source imaging in neonates with postasphyxial seizures. We describe here our method and compare the dipole seizure localization results with acute perinatal lesions seen on brain MRI in 10 full-term infants with neonatal encephalopathy. Through experimental studies, we also explore the sensitivity of our method to the electrode positioning errors and the variations in neonatal skull geometry and conductivity. The localization results of 45 focal seizures from 10 neonates are compared with the visual analysis of EEG and MRI data, scored by expert physicians. In 9 of 10 neonates, dipole locations showed good relationship with MRI lesions and clinical data. Our experimental results also suggest that the variations in the used values for skull conductivity or thickness have little effect on the dipole localization, whereas inaccurate electrode positioning can reduce the accuracy of source estimates. The performance of our fused method indicates that ictal EEG source imaging is feasible in neonates and with further validation studies, this technique can become a useful diagnostic tool.

Automated EEG inter-burst interval detection in neonates with mild to moderate postasphyxial encephalopathy

EEG inter-burst interval (IBI) and its evolution is a robust parameter for grading hypoxic encephalopathy and prognostication in newborns with perinatal asphyxia. We present a reliable algorithm for the automatic detection of IBIs. This automated approach is based on adaptive segmentation of EEG, classification of segments and use of temporal profiles to describe the global distribution of EEG activity. A pediatric neurologist has blindly scored data from 8 newborns with perinatal postasphyxial encephalopathy varying from mild to severe. 15 minutes of EEG have been scored per patient, thus totaling 2 hours of EEG that was used for validation. The algorithm shows good detection accuracy and provides insight into challenging cases that are difficult to detect.

Time varying neonatal seizure localization

BACKGROUND

A common cause for damage to the neonatal brain is a shortage in the oxygen supply to the brain or asphyxia. Neonatal seizures are the most frequent manifestation of neonatal neurologic disorders. Multichannel EEG recordings allow topographic localization of seizure foci.

OBJECTIVES

We want to objectively determine the spatial distribution of the seizure on the scalp, the location in time and order the dominant sources in the brain based on their strength.

METHODS

In this paper we combine a method based on higher order CP-decomposition with subsequent singular value decomposition (SVD).

RESULTS

We illustrate the abilities of the method on simulated as well as on real neonatal seizure EEG.

CONCLUSIONS

The proposed method provides reliable time and spatial information about the seizure, gives a clear overview of what is going on in the EEG and allows easy interpretation.

Technical standards for recording and interpretation of neonatal electroencephalogram in clinical practice

Neonatal electroencephalogram (EEG), though often perceived as being difficult to record and interpret, is relatively easy to study due to the immature nature of the brain, which expresses only a few well-defined set of patterns. The EEG interpreter needs to be aware of the maturational changes as well as the effect of pathological processes and medication on brain activity. It gives valuable information for the treatment and prognostication in encephalopathic neonates. In this group, serial EEGs or EEG monitoring often gives additional information regarding deterioration/improvement of the brain function or occurrence of seizures.

Heart rate changes are insensitive for detecting postasphyxial seizures in neonates

We studied heart rate (HR) changes during 169 seizures (mean 12 per patient, range 8 to 18) in 14 neonates with severe birth asphyxia. HR changes were found in 21 seizures (12.4%) in eight patients (HR increases in four, decreases in one, and both patterns in three patients), suggesting the existence of neonatal cerebral hemispheric connections with brainstem autonomic regulatory centers. HR monitoring appears to be insensitive for detecting postasphyxial neonatal seizures.

[Lichen sclerosus et atrophicus as a cause of genital lesions in a girl]

In a 10-year old girl with irritated vulva lichen sclerosus et atrophicus (LSA) was diagnosed. She was successfully treated with local application of equal amounts of a cortisol ointment and zinc oil. LSA is a disease of the skin infrequently seen in children, and then mostly in girls. Diagnosis is based on typical lesions in the anogenital region (sharply delineated ivory discoloration, moderate sclerosis and atrophy, haemorrhagic erosions). Knowledge of this disease is important in order to distinguish it from sexual abuse.

[Green amniotic fluid as initial symptom of high intestinal obstruction in infants]

At the birth of two children the amniotic fluid was green colored. The Apgar scores were good. Because of bilious vomiting and food retention, respectively, an open stomach tube was inserted, out of which bilious stomach contains were drained. The cause of green amniotic fluid was not meconium production or infection with Listeria monocytogenes, but mixing with green bile. At further investigation the children both proved to have a high intestinal obstruction distal of the papilla duodeni major.