Management Outcome of Severe Laryngomalacia at Queen Sirikit National Institute Child Health

BACKGROUND

Outcomes of the different management in severe laryngomalacia (LM) have not been evaluated.

OBJECTIVE

To identify the management practices and to evaluate the outcomes in patient with severe LM.

MATERIAL AND METHOD

The medical records of LM at Queen Sirikit National Institute Child Health between January2007 and December 2012 were retrospectively reviewed.

RESULTS

Severe LM 69.8% (30/43) were found in patients diagnosed with LM. Type B (complete collapse) at 46.67% were the most common finding. Decision of management were made individually based on consideration of disease severity and comorbidity. The outcomes after management were evaluated by pre- and post-symptoms score. Post-symptoms scores were statistically significant better than pre-symptom score in all management (observation p<0.001, laser supraglottoplasty p = 0.003, and tracheotomy p = 0.001).

CONCLUSION

Our management in severe LM include: observation, laser supraglottoplasty, and tracheostomy. The overall post-management outcome were satisfactory but the present study was limited to relatively small number of patients.

Short- and Long-Term Outcomes for Extremely Preterm Infants

Prematurity is the leading cause of infant mortality worldwide. In developed countries, extremely preterm infants contribute disproportionately to both neonatal and infant mortality. Survival of this high-risk population has incrementally improved in recent years. Despite these improvements, approximately one in four extremely preterm infants dies during the birth hospitalization. Among those who survive, respiratory and other morbidities are common, although their effect on quality of life is variable. In addition, long-term neurodevelopmental impairment is a large concern for patients, clinicians, and families. However, the interplay of multiple factors contributes to neurodevelopmental impairment, with measures that change over time and outcomes that can be difficult to define and predict. Understanding outcomes of extremely preterm infants can help better counsel families regarding antenatal and postnatal care and guide strategies to improve survival without morbidity. This review summarizes recent evidence to provide an overview into the short- and long-term outcomes for extremely preterm infants.

Borderline viability--neonatal outcomes of infants in Singapore over a period of 18 years (1990 - 2007)

INTRODUCTION

This study assesses the trends and predictors of mortality and morbidity in infants of gestational age (GA) <27 weeks from 1990 to 2007.

MATERIALS AND METHODS

This is a retrospective cross-sectional cohort study of infant deliveries between 1990 and 2007 in the largest perinatal centre in Singapore. This is a study of infants born at <27 weeks in 2 Epochs (Epoch 1 (E1):1990 to 1998, Epoch 2 (E2):1999 to 2007) using logistic regression models to identify factors associated with mortality and composite morbidity. The main outcomes that were measured were the trends and predictors of mortality and morbidity.

RESULTS

Four hundred and eight out of 615 (66.3%) live born infants at 22 to 26 weeks survived to discharge. Survival improved with increasing GA from 22% (13/59) at 23 weeks to 87% (192/221) at 26 weeks (P <0.01). Survival rates were not different between E1 and E2, (61.5% vs 68.8%). In logistic regression analysis, higher survival was independently associated with increasing GA and birthweight, while airleaks, severe intraventricular haemorrhage (IVH) and necrotizing enterocolitis (NEC) contributed to increased mortality. Rates of major neonatal morbidities were bronchopulmonary dysplasia (BPD) (45%), sepsis (35%), severe retinopathy of prematurity (ROP) (31%), severe IVH/ periventricular leucomalacie (PVL) (19%) and NEC (10%). Although composite morbidity comprising any of the above was not significantly different between the 2 Epochs (75% vs 73%) a decreasing trend was seen with increasing GA (P <0.001). Composite morbidity/ mortality was significantly lower at 26 weeks (58%) compared to earlier gestations (P <0.001, OR 0.37, 95% CI, 0.28 to 0.48) and independently associated with decreasing GA and birth weight, male sex, hypotension, presence of patent ductus arteriosus (PDA) and airleaks.

CONCLUSION

Increasing survival and decreasing composite morbidity was seen with each increasing week in gestation with marked improvement seen at 26 weeks. Current data enables perinatal care decisions and parental counselling.

Congenital hypothyroidism due to defects of thyroid development and mild increase of TSH at screening: data from the Italian National Registry of infants with congenital hypothyroidism

CONTEXT

Over the years lower TSH cutoffs have been adopted in some screening programs for congenital hypothyroidism (CH) worldwide. This has resulted in a progressive increase in detecting additional mild forms of the disease, essentially with normally located and shaped thyroid. However, the question of whether such additional mild CH cases can benefit from detection by newborn screening and early thyroid hormone treatment is still open.

OBJECTIVE

The aim of this study was to estimate the frequency of cases with mild increase of TSH at screening in the Italian population of babies with permanent CH and to characterize these babies in terms of diagnosis classification and neonatal features.

METHODS

Data recorded in the Italian National Registry of infants with CH were analyzed.

RESULTS

Between 2000 and 2006, 17 of the 25 Italian screening centers adopted a TSH cutoff at screening of <15.0 μU/mL. It was found that 21.6% of babies with permanent CH had TSH at screening of 15.0 μU/mL or less, whereas this percentage was 54% in infants with transient hypothyroidism. Among the babies with permanent CH and mild increase of TSH at screening (≤15 μU/mL), 19.6% had thyroid dysgenesis with serum TSH levels at confirmation of the diagnosis ranging from 9.9 to 708 μU/mL. These babies would have been missed at screening if the cutoff had been higher.

CONCLUSIONS

Lowering TSH cutoff in our country has enabled us to detect additional cases of permanent CH, a number of which had defects of thyroid development and severe hypothyroidism at confirmation of the diagnosis.

[Diagnostic endoscopy of the nasal cavity and nasopharynx in premature newborn infants]

Disturbed nasal breathing in the children always was a topical socio-medical problem and has remained such up to now. The objective of the present investigation was to estimate the potential of modern endoscopic techniques for diagnostics of disturbed nasal breathing in the premature infants and to develop therapeutic measures aimed at the prevention of destructive changes in the nose during therapy with the use of continuous positive airway pressure (CPAP). The study included 43 children ranging in the age from 1 month to 2 years (24 boys and 19 girls). All the newborn babies were transferred to the department of resuscitation and intensive therapy for the urgent treatment including respiratory support with the use of the CPAP technique. The endoscopic surveillance made it possible to exactly determine the causes responsible for the disturbances of nasal breathing in the children who survived the critical conditions, to estimate the anatomical and functional conditions of the nasopharyngeal structures, and to develop therapeutic and preventive measures to protect the nose from further destructive changes.

Patent ductus arteriosus evaluation by serial echocardiography in preterm infants

BACKGROUND

Patent ductus arteriosus (PDA) is associated with morbidity and mortality in premature neonates.

METHODS

The effect of serial echocardiography performed by a neonatologist and early targeted medical PDA treatment was evaluated and compared to historical controls. One hundred ninety-two infants <1,500 g were included and 45 infants had a PDA.

RESULTS

Serial echocardiography allowed significantly earlier identification and treatment of PDA versus awaiting the evolution of clinical signs. Severe intraventricular haemorrhage and ventilator days were significantly decreased in the studied cohort following the introduction of echocardiography. In addition, hospital stay was also reduced in the non-PDA group and other outcomes were unchanged.

CONCLUSION

Serial echocardiography for PDA evaluation, performed by a neonatologist trained in echo, may reduce morbidity in preterm infant.

Venous subtypes of preterm periventricular haemorrhagic infarction

BACKGROUND

Periventricular haemorrhagic infarction (PVHI) is a complication of preterm birth that may lead to impairment and disability. Early diagnosis is possible by cranial ultrasonography (CUS). Extensive PVHI lesions can be graded using a scoring system that relates to outcome, based on CUS characteristics. Data on more subtle unilateral forms of PVHI are lacking.

OBJECTIVE

To refine the PVHI classification by relating subtypes to affected veins and to evaluate the effects of these anatomical subtypes on neurological outcome.

METHODS

Retrospective analysis of images and neurological outcome of 20 preterm infants with unilateral PVHI. Based on affected veins, PVHI was classified into six subtypes. Sonographic templates of infarct types are provided in the coronal and parasagittal planes. Standardised neurological examinations were done (according to Amiel-Tison and Touwen examinations) and children were classified as: normal, mildly or definitely abnormal. The outcome was based on the most recent neurological examination, at a corrected age of 1 (n = 7), 2 (n = 5), 3 (n = 5) or 5 (n = 3) years.

RESULTS

PVHI classification of the 20 patients was as follows: temporal (n = 3), pure caudate (n = 3), anterior terminal (n = 6), complete terminal (n = 3), extensive (n = 4), other (n = 1). With one exception, only PVHI patients showing the latter three subtypes had developed severe spastic contralesional hemiplegia.

CONCLUSIONS

The classification was developed for PVHI correlates with neurological outcome. This refined classification can help clinicians in predicting neurological outcome at an early stage, with a subsequent targeted rehabilitation schedule instituted early in life.

Outcome of extremely low birth weight survivors at school age: the influence of perinatal parameters on neurodevelopment

Extremely low birth weight (ELBW) is associated with impaired neurodevelopmental outcome in infancy. Information on the long-term cognitive and neurological consequences of ELBW is scarce. We aimed to identify the perinatal and neonatal factors of ELBW infants associated with adverse cognitive and neurological outcome at school age. A regional cohort of 135 ELBW infants born between 1993 and 1998 was prospectively evaluated at 3, 6, 12, and 18 months postmenstrual age and at yearly intervals up to age 10 years. The comprehensive follow-up programme for high-risk infants included neurological examinations and psychometric evaluations. According to the overall results of these tests, children were classified as either being normal or having minor or major impairment. At a mean age of 8.4 (SD: 1.6) years, 43% of children had survived without any impairment. Minor impairment was diagnosed in 39% and major impairment in 18% of assessed children. The proportion of disabled school children rose with decreasing gestational age. The following neonatal complications were significant risk factors for developing major or minor impairment at school age: an increase in head circumference < 6 mm per week (OR 4.0, 95% CI: 1.1-14.8), parenteral nutrition > or = 6 weeks (OR 2.5, 95% CI: 1.1-6.0), and mechanical ventilation > 14 days (OR 2.3, 95% CI: 1.0-5.1). High-grade intraventricular haemorrhage (IVH) and/or PVL (OR 13.3, 95% CI: 4.0-44.9), neonatal seizures (OR 5.2, 95% CI: 1.2-22.4) and bowel perforation, and/or necrotizing enterocolitis (OR 4.4, 95% CI: 1.1-17.0) were significant risk factors for developing major impairment. In spite of the relatively large proportion of normal children, ELBW remains an important risk factor for neurodevelopmental impairment at school age. Thus, measures to prevent complications such as necrotizing enterocolitis, cerebral haemorrhage, and undernutrition remain important goals for neonatal intensive care.

[Pathological patterns in neonatal EEG before 30 weeks of gestational age]

Pathological features on very premature EEG concern background abnormalities and abnormal patterns. Positive rolandic sharp waves keep an important place regarding diagnosis and prognosis. Background abnormalities give essential complementary informations. Unusual patterns (abnormal localisation or morphological aspect, high amplitude) remain early markers of cerebral lesions. Analysis of these pathological features must always take into account treatment given to the baby, which can by itself modify the EEG.

A simple presurgical necrotizing enterocolitis-mortality scoring system

OBJECTIVE

To assess the relationship between early laboratory parameters, disease severity, type of management (surgical or conservative) and outcome in necrotizing enterocolitis (NEC).

STUDY DESIGN

Retrospective collection and analysis of data from infants treated in a single tertiary care center (1980 to 2002). Data were collected on disease severity (Bell stage), birth weight (BW), gestational age (GA) and pre-intervention laboratory parameters (leukocyte and platelet counts, hemoglobin, lactate, C-reactive protein).

RESULTS

Data from 128 infants were sufficient for analysis. Factors significantly associated with survival were Bell stage (P<0.05), lactate (P<0.05), BW and GA (P<0.01, P<0.001, respectively). From receiver operating characteristics curves, the highest predictive value resulted from a score with 0 to 8 points combining BW, Bell stage, lactate and platelet count (P<0.001). At a cutoff level of 4.5 sensitivity and specificity for predicting survival were 0.71 and 0.72, respectively.

CONCLUSION

Some single parameters were associated with poor outcome in NEC. Optimal risk stratification was achieved by combining several parameters in a score.

Neonatal transport of very low birth weight infants in Jerusalem, revisited

BACKGROUND

Maternal transport, rather than neonatal transport, to tertiary care centers is generally advocated. Since a substantial number of premature deliveries still occur in hospitals with level I and level II nurseries, it is imperative to find means to improve their outcome.

OBJECTIVES

To compare the neonatal outcome (survival, intraventricular hemorrhage and bronchopulmonary dysplasia) of inborn and outborn very low birth weight infants, accounting for sociodemographic, obstetric and perinatal variables, with reference to earlier published data.

METHODS

We compared 129 premature infants with birth weights of 750-1250 g delivered between 1996 and 2000 in a hospital providing neonatal intensive care to 99 premature babies delivered in a referring hospital. In the statistical analysis, variables with a statistical significant association with the outcome variables and dissimilar distribution in the two hospitals were identified and entered together with the hospital of birth as explanatory variables in a logistic regression.

RESULTS

Accounting for the covariates, the odds ratios (outborns relative to inborns) were 0.31 (95% confidence interval = 0.11-0.86, P = 0.03) for mortality, 1.37 (95% CI = 0.64-2.96, P = 0.42) for severe intraventricular hemorrhage, and 0.86 (95% CI = 0.38-1.97, P = 0.78) for bronchopulmonary dysplasia. The odds ratio for survival without severe intraventricular hemorrhage was 1.10 (95% CI = 0.55-2.20, P = 0.78). Comparing the current results with earlier (1990-94) published data from the same institution showed that mortality decreased in both the outborn and inborn infants (OR = 0.23, 95% CI = 0.09-0.58, P = 0.002 and 0.46; 95% CI = 0.20-1.04, P = 0.06, respectively), but no significant change in the incidence of severe intraventricular hemorrhage or brochopulmonary dysplasia was observed. Increased survival was observed also in these infants receiving surfactant, more so among the outborn. The latter finding could be attributed to the early, pre-transport surfactant administration, implemented only in the current study.

CONCLUSIONS

Our data suggest that very low birth weight outborn infants may share an outcome comparable with that of inborn babies, if adequate perinatal care including surfactant administration is provided prior to transportation to a tertiary center.

Increasing illness severity in very low birth weight infants over a 9-year period

Background

Recent reports have documented a leveling-off of survival rates in preterm infants through the 1990's. The objective of this study was to determine temporal changes in illness severity in very low birth weight (VLBW) infants in relationship to the outcomes of death and/or severe IVH.

Methods

Cohort study of 1414 VLBW infants cared for in a single level III neonatal intensive care unit in Delaware from 1993–2002. Infants were divided into consecutive 3-year cohorts. Illness severity was measured by two objective methods: the Score for Neonatal Acute Physiology (SNAP), based on data from the 1^st day of life, and total thyroxine (T₄), measured on the 5^th day of life. Death before hospital discharge and severe intraventricular hemorrhage (IVH) were investigated in the study sample in relation to illness severity. The fetal death rate was also investigated. Statistical analyses included both univariate and multivariate analysis.

Results

Illness severity, as measured by SNAP and T_4, increased steadily over the 9-year study period with an associated increase in severe IVH and the combined outcome of death and/or severe IVH. During the final 3 years of the study, the observed increase in illness severity accounted for 86% (95% CI 57–116%) of the variability in the increase in death and/or severe IVH. The fetal death rate dropped from 7.8/1000 (1993–1996) to 5.3/1000 (1999–2002, p = .01) over the course of the study.

Conclusion

These data demonstrate a progressive increase in illness in VLBW infants over time, associated with an increase in death and/or severe IVH. We speculate that the observed decrease in fetal death, and the increase in neonatal illness, mortality and/or severe IVH over time represent a shift of severely compromised patients that now survive the fetal time period and are presented for care in the neonatal unit.

Treadmill training for an infant born preterm with a grade III intraventricular hemorrhage

BACKGROUND AND PURPOSE

Research has documented the feasibility and benefit of treadmill training in children with cerebral palsy and Down syndrome. The purposes of this case report are: (1) to determine the feasibility of treadmill training in an infant at high risk for neuromotor dysfunction and (2) to describe the child's treadmill stepping patterns following treadmill training.

CASE DESCRIPTION

The male infant, who had a grade III intraventricular hemorrhage following premature birth, began physical therapy and treadmill training at 51/4 months corrected age. Treadmill training was conducted 3 times weekly and videotaped weekly. Videotape analysis determined number of steps, step type, and foot position.

OUTCOMES

Except for foot position, trends in treadmill stepping were similar to those of studies with infants not at high risk for neuromotor disabilities.

DISCUSSION

This case report shows that treadmill training is feasible for an infant at high risk for neuromotor disabilities and may be associated with more mature stepping characteristics. Future research should evaluate optimum treadmill training parameters and long-term developmental outcomes.

[Diagnosis and characteristics of the clinical course of necrotizing enterocolitis in children]

Necrotizing enterocolitis (NEC) is a disease of unknown etiology affecting mainly premature newborns and occurring in about 1 to 7% of all admissions to neonatal intensive care units. Among the greatest problems is the early diagnosis and adequate and timely treatment, surgery included. In the last quarter of the century the survival rate of premature infants was gradually increasing in national regions and worldwide and accordingly there is an increasing number of babies with NEC. To date, to treat patients with the diagnosed enterocolitis is a complicated problem. The mortality rate among the children remains high. In the period from 1978 to 2000 432 patients with NEC were admitted to the St. Petersburg Center of Neonatal Surgery in the Children Hospital N 1,300 of them requiring surgical interventions. The author's personal experience with the diagnosis and treatment of the disease allowed three main forms of the clinical course of the disease to be established: superacute, acute and subacute.

HRQL and severity of brain ultrasound findings in a cohort of adolescents who were born preterm

PURPOSE

To determine whether health-related quality of life (HRQL) in a cohort of adolescents who were born prematurely is related to the severity of brain ultrasound examination findings during the newborn period.

METHODS

This study uses a historical, prospective methodology to investigate the 84 members of a cohort of infants born prematurely (<33 weeks gestation) at Thomas Jefferson University Hospital during a 25-month period, from 1979 to 1981. We extracted the following information from their neonatal intensive care unit (NICU) records: ultrasound examination findings (graded for intraventricular hemorrhage (IVH) and periventricular leukomalacia (PVL); and records of medical illness (respiratory, gastrointestinal, and other) during the NICU stay. We followed-up the members of this cohort 18-19 years later, obtaining data on 53 (63%). We correlated the NICU data with the following self-report outcome measures: HRQL, Disabilities Questionnaire [parental report indicating the severity of complications of prematurity (DISAB)] and psychological assessment tests [Beck Depression Inventory (BDI), Coopersmith Self-Esteem Inventory (CSEI), and Body Shape Questionnaire (BSQ)]. We used the method of multiple discriminant function analysis to determine statistical significance of differences between the two ultrasound groups, grades 0-2 IVH, no PVL vs. grades 3-4 IVH and/or PVL.

RESULTS

A statistically significant difference was obtained between the two ultrasound groups (grades 0-2 IVH, no PVL vs. grades 3-4 IVH and/or PVL) among the HRQL variables (Wilks' lambda =.764, df = 5, p <.470). The relative contribution of dependent variables (HRQL1, HRQL2, HRQL3, HRQL4, DISAB) to the group separation was assessed through the interpretation of discriminant function-variable correlation. HRQL1 and DISAB made the largest discriminant between groups, which is supported by results from univariate Student's t-tests. Study subjects with grades 3-4 IVH and/or PVL ultrasound findings obtained much lower HRQL1 scores (better overall estimation of HRQL) and much higher DISAB scores than subjects with grades 0-2 IVH, no PVL ultrasound findings.

CONCLUSIONS

It appears that the lower an adolescent's score on overall HRQL (HRQL1), (i.e., the better the self-perceived overall quality of life), the more likely he or she displayed the higher severity of brain ultrasound examination findings during the NICU hospitalization. A larger study of premature infants who are followed into adolescence is required to better understand the factors that determine the association of IVH and PVL with HRQL.

Analysis by gestational age of cerebral palsy in singleton births in north-east England 1970-94

We report from a well-established cerebral palsy (CP) register the changes in CP rates by gestational age for singleton births over a 25-year period in north-east England. The gestational ages of numerators and denominators are of high accuracy back to 1970 because academic units in paediatrics and obstetrics were studying the assessment of gestational age in individual infants, and the distribution of gestational age across all births in the north-east from the 1960s. The rate of CP rose between 1970-75 and 1990-94 from 1.6 to 2.3 per 1000 singleton neonatal survivors, a rise of 0.7/1000 [95% CI 0.2, 1.3]. There was little change in the rate of CP in term infants whereas in preterm infants (<37 weeks) it rose from 5.5 to 16.8, a rise of 11.3/1000 [95% CI 5.9, 16.8]. Rises occurred in the three preterm gestational age bands <28, 28-31, 32-36 weeks with the most marked rise in those <28 weeks from 0 to 112.7. The proportion of all cases of CP arising in the preterm group rose from 19% to 45%; and the proportion of the severest cases arising in the preterm group rose from 8% to 55%. In those born after 32 weeks, there is a preponderance of small-for-gestation infants, with 10% more than two standard deviations below the mean. All types of CP are more common in infants below average weight for gestation and this is most marked for the non-spastic types that are almost only seen in term, small-for-gestation infants. Gestational age is the crucial determinant of rate of CP and the increase in prevalence seen over the past 25 years is due to increased rates in preterm infants, not term infants. Both conclusions, suspected from birthweight analyses, are now demonstrated conclusively, with the contribution coming from those 32-36 weeks gestation as well as very preterm infants.

The changing face of surgical indications for necrotizing enterocolitis

PURPOSE

The aim of this study was to compare the proportion of operations for acute necrotizing enterocolitis (NEC) and post NEC strictures.

METHODS

The authors reviewed 195 charts of children referred to our institution for NEC or post-NEC strictures between 1990 and 1999. Seventy-one children were classified as Bell stage I and were excluded. The remaining 124 patients were classified as either Bell stage II or III and formed the basis of our study. These patients were subdivided into 2 groups: (1) group I (n = 69) comprised patients treated from 1990 until 1994 and (2) group II (n = 55) from 1995 until 1999. Statistical analysis consisted of X(2) and Student's t tests. Significance occurred when P less-than-or-equal 0.05.

RESULTS

Both groups were similar with regard to sex, obstetrical history, indomethacin use, umbilical artery catheter use, and enteral feeding. The total operative rate for all patients with either acute NEC or post NEC strictures increased over time from 46% (32 of 69) in group I to 69% (38 of 55) in group II (P <.01). Specifically, post-NEC stricture was the initial operation in 16% (5 of 32) of group I patients versus 37% (14 of 38) of group II patients (P <.05). Subdividing each group by method of treatment of their NEC showed that medically treated patients had an increased incidence of stricture over time (group I, 15% v. group II, 48%; P <.01). Surgically treated children maintained a similar rate of stricture (group I, 36% v. group II, 33%). The mortality rate was comparable in both groups.

CONCLUSIONS

At our institution, the total operative rate for necrotizing enterocolitis has increased over the last 10 years. This is because of 2 factors: (1) an increase in the percentage of stage III patients and (2) an increase in referrals for post--necrotizing enterocolitis strictures. No specific criteria could be identified to predict which patients were at risk for post--necrotizing enterocolitis strictures after medical treatment.

Tube enterostomy in the management of intestinal atresia

A simple technique was used successfully for retraining maximum bowel length in a premature baby born with type 3A jejunal atresia. Primary end-to-end anastomosis of the tip of the dilated proximal segment to the remaining viable distal 5 cm of ileum was performed. A tube passed via the cecum proximally into the small bowel acted as a stent for the anastomosis and decompression of the bowel contents in the proximal dilated segment. This simple method may be a viable option to avoid resection of the dilated segment when the bowel length is marginal.

Umbilical vein interleukin 6 and tumor necrosis factor alpha plasma concentrations in the very preterm infant

OBJECTIVE

To examine the relationship between umbilical vein plasma concentrations of interleukin 6 (IL-6) and tumor necrosis factor (TNF)-alpha and early neonatal sepsis in the very preterm infant, and the histopathologic findings of chorioamnionitis in the placentas from these pregnancies.

METHODS

A prospective study was conducted in 43 very preterm, singleton infants delivered at or before 32 weeks of gestation. IL-6 and TNF-alpha were measured by enzyme-linked immunoassay. Placentas from these pregnancies were histologically examined for the presence of chorioamnionitis. Infants were prospectively classified as confirmed sepsis group, clinical sepsis group or control group. IL-6 and TNF-alpha plasma concentrations were not normally distributed, so they were transformed to their natural log values for statistical analysis.

RESULTS

The enrolled infants had a mean gestational age of 27.2 +/- 2.7 weeks and a mean birth weight of 956 +/- 325 g. Three (7%) infants had confirmed sepsis, 18 (42%) were in the clinical sepsis group and 22 (51%) were in the control group. IL-6 concentrations but not TNF-alpha were significantly higher (P < 0.05) in the confirmed (8.9 +/- 1.7) and clinical sepsis (5.5 +/- 2.4) groups in comparison with the control group (2.1 +/- 1.6). We examined 42 placentas. Twenty-three (55%) had no evidence of chorioamnionitis, 1 (2%) had mild grade, 8 (19%) had a moderate grade and 10 (24%) had a severe grade of chorioamnionitis. IL-6 was significantly elevated in the moderate (5.9 +/- 1.6 vs. 1.9 +/- 1.6) and severe grade (7.2 +/- 2.3 vs. 1.9 +/- 1.6) of chorioamnionitis, in the presence of acute deciduitis (6.0 +/- 2.7 vs. 2.1 +/-1.8), chorionic vasculitis (6.8 +/- 2.1 vs. 2.2 +/- 1.9) and funisitis (7.3 +/- 1.9 vs. 2.7 +/- 2.3) (P < 0.05) TNF-alpha plasma concentrations were not significantly different.

CONCLUSION

An elevated umbilical vein IL-6 concentration is a good indicator of sepsis syndrome in the very preterm infant and also correlates with histologic chorioamnionitis in these pregnancies.

[Classification of intracranial hemorrhage in premature infants]

The most common classification of intracranial haemorrhage in premature infants into four degrees of severity is based on the results of CT-scans. However, this classification does not adequately account for some pathophysiological and morphological changes. For this reason, the paediatric section of DEGUM developed a new method of classification. This classification distinguishes more precisely between the bleeding itself and secondary changes, such as posthaemorrhagic ventricular dilation, which were excluded from the revised classification. The new system contains three levels: Grade I: subependymal haemorrhage, grade II: intraventricular haemorrhages taking up < 50% of the ventricular volume, grade III: intraventricular haemorrhages of > 50% of ventricular volume. Areas of increased echo levels within the brain tissue (formerly grade IV) which are caused by haemorrhagic infarction are now taken as a separate entity. The morphological description lists the side and the location of the haemorrhagic infarction as well as its size, which is classified into 'small' (< or = 1 cm in diameter), 'medium' (1 < or = 2 cm) and large (> 2 cm). Bleeding into the basal ganglia, cerebellum and brainstem are separate entities. In post-haemorrhagic ventricular dilation the distinction is made between self-limiting transient dilation and hydrocephalus requiring treatment.

Indomethacin tocolysis increases postnatal patent ductus arteriosus severity

Postnatally, therapeutic indomethacin administration is usually effective in mediating patent ductus arteriosus (PDA) constriction in premature infants. There are infants, however, who remain resistant to indomethacin and require more aggressive surgical intervention to facilitate ductal closure. Indomethacin tocolysis has been reported to increase the incidence of persistent PDA in premature infants. It was our impression that infants exposed to antenatal indomethacin not only suffered from an increased incidence of PDA, but that they were more symptomatic from PDA and that for them, PDA was more resistant to medical closure. It is this observation that we sought to examine in this study.

METHODS

Medical records of all mothers and premature neonates with birth weight </=1500 g, admitted to the neonatal intensive care unit of the Shaare Zedek Medical Center during 1996 and 1997, who survived for at least 1 week, were reviewed retrospectively. Data on maternal indomethacin and steroid exposure, birth weight and gestational age, and ductus status and treatment were analyzed. In our obstetrics department, indomethacin is the medication of choice to inhibit premature labor. Mothers who arrive in premature labor are started on indomethacin therapy, if delivery is not imminent. All infants </=1500 g were studied by a pediatric cardiologist between 24 and 72 hours of life using two-dimensional echocardiography with color flow mapping to assess ductal patency. Decisions to treat were based on echocardiographic evidence of PDA, along with any of the following clinical signs: bounding pulses, diastolic pressure of </=25 mm Hg, pulmonary plethora and/or cardiomegaly on chest x-ray, or increasing oxygen requirement with no other explanation. Initial treatment is with indomethacin, if there are no contraindications. Our general approach is to begin therapy with a continuous indomethacin infusion, followed by a course of bolus indomethacin if the infant does not respond. However, each attending neonatologist may treat according to his/her preference (ie, bolus vs continuous). All infants with PDA are followed with serial echocardiographic examinations until the ductus is closed.

RESULTS

A total of 105 premature infants met the above criteria. Thirty-six of these 105 infants had echocardiographic signs of a PDA (34.3%). Those with PDA were less mature (gestational age, 28.9 +/- 2.6 vs 30.3 +/- 2.6 weeks, respectively) and tended to be smaller (1060 +/- 270 vs 1166 +/- 261 g). Of the 36 infants with PDA, 15 (42%) resolved spontaneously and 21 (58%) were symptomatic and required treatment with indomethacin. There were no differences in gestational age or birth weight between infants whose PDA resolved spontaneously and those requiring indomethacin therapy. Four of the 21 (19%) treated infants remained unresponsive to indomethacin and required ductal ligation. Of 17 infants with PDA who responded to indomethacin therapy, 1 (6%) was treated with a single course of bolus indomethacin, to which he responded, and 16 (94%) were treated with continuous indomethacin and responded promptly. The differences in therapeutic responsiveness to initial treatment with continuous vs bolus indomethacin were not significant. Of the 105 infants, 29 were exposed to indomethacin tocolysis. Those who were exposed to antenatal indomethacin and those who were not were well-matched with respect to birth weight and gestational age. Fifteen (52%) of the 29 exposed infants versus 18 (24%) of the 76 infants not exposed to antenatal indomethacin developed a PDA postnatally (relative risk = 2.1; 95% confidence interval: 1.22-3.74), and 45% of the antenatally exposed infants versus 12% of the nonexposed infants were symptomatic and required indomethacin (relative risk = 1.9; 95% confidence interval: 1.17-3.20). Four of the exposed infants versus none of the unexposed infants required surgical ligation. (ABSTRACT TRUNCATED)

Chronic physiologic instability is associated with neurodevelopmental morbidity at one and two years in extremely premature infants

OBJECTIVE

The objective of this study was to evaluate the relationships between chronic physiologic instability, as assessed by the cumulative daily Score for Neonatal Acute Physiology (SNAP), and neurodevelopmental morbidity in premature infants at 1 year and at 2 to 3 years of age.

DESIGN

The subjects of this retrospective study were extremely premature (</=30 weeks' gestational age [GA]) infants born in 1993 and 1994 who were seen in follow-up at least once between 1 and 3 years of age. Cumulative daily SNAP scores were calculated over the entire neonatal intensive care unit course for 96 infants (mean GA, 27.3 +/- 1.6 weeks; mean birth weight, 1065 +/- 270 g). The Mental and Psychomotor Developmental (MDI and PDI) of the Bayley Scales of Infant Development (II) were administered at 1 year and at 2 to 3 years of age; the Receptive-Expressive Emergent Language Scale (REEL) was administered at 2 to 3 years of age. To compare the most stable infants with the most unstable infants, the subjects were divided into three quartile groups based on their cumulative SNAP scores (<25th percentile, 25 to 75th percentile, and >75th percentile). MDI, PDI, and REEL scores were compared for the three groups using analysis of variance. To evaluate the relative contributions of physiologic stability, intracranial abnormalities, GA, and early postnatal nutritional intakes, multiple regression analyses were performed using cumulative SNAP score, an intraventricular hemorrhage (IVH) score (incorporating IVH and periventricular leukomalacia), GA, and a weight-change score for the first month as independent variables, and MDI, PDI, and REEL quotients as dependent variables. Regression analyses were repeated, with cumulative SNAP subscores for oxygenation, hypotension, acidosis, and hypoxia/ischemia included with IVH score, GA, and first month weight z score change as independent variables, and MDI, PDI, and REEL quotients as dependent variables.

RESULTS

The infants with the highest degree of physiologic instability (cumulative SNAP scores greater than the 75th percentile) had significantly lower MDI scores at 1 year of age and lower PDI scores at 1 year and at 2 to 3 years of age than did infants who were more physiologically stable. Sixty-seven percent of infants with cumulative SNAP scores greater than the 75th percentile had neurodevelopmental abnormalities at 2 to 3 years of age (cerebral palsy or delayed mental, motor, or language development). Using multiple regression analyses, higher cumulative SNAP scores, IVH scores, and GA were associated with lower 1-year MDI scores. Higher cumulative SNAP scores and IVH scores were associated with lower 1-year PDI scores. By 2 years, only higher cumulative SNAP scores were significantly associated with lower MDI and PDI scores. With respect to language development, only lower weight-change scores over the first month were significantly associated with poorer receptive language development. Lower weight-change scores over the first month and higher hypotension scores were significantly associated with poorer expressive language development. In the secondary regression analyses, higher IVH score, higher cumulative oxygenation scores, and higher hypoxia/ischemia scores all were significantly associated with lower 1-year MDI scores. By 2 to 3 years of age, only higher oxygenation scores were significantly associated with lower MDI scores.

CONCLUSIONS

Prolonged physiologic instability was associated with deleterious neurodevelopmental consequences for extremely premature infants through 2 to 3 years of age, independent of effects of intracranial abnormalities and GA.

Multisystem organ failure and capillary leak syndrome in severe necrotizing enterocolitis of very low birth weight infants

BACKGROUND

Classification systems for necrotizing enterocolitis (NEC) in preterm infants have been developed to define severity grades relevant for treatment and prognosis. Multisystem organ failure (MSOF) and capillary leak syndrome (CLS) also have prognostic value in these patients. The aim of this retrospective study was to investigate the incidence and predictive value of MSOF and CLS according to the classification criteria.

METHODS

The records of 1,022 very low birth weight infants admitted from 1982 to 1996 were reviewed for diagnosis of NEC stage IIA or higher (classification of Walsh and Kliegman). Among those patients (n = 50) the incidence of MSOF and CLS was determined, separately for surgical or conservative treatment.

RESULTS

Twelve patients were assigned to stage II, 22 to stage IIIa, and 16 to stage IIIb; 31 infants underwent operation. Mortality rate was not influenced by the grade. In eight patients only gastrointestinal symptoms were found, whereas in 23 patients, up to three organ systems and in 19 patients, four or more organ systems were affected. Mortality depended on the number of involved organ systems. CLS occurred postoperatively in 10 of the 31 infants; eight of them died.

CONCLUSION

The prognostic values of MSOF and CLS are higher than that of classification criteria in NEC of VLBW infants.

Predictors of individual differences in attention among low birth weight children

The prediction of early childhood attention problems was investigated prospectively within a sample of low birth weight children. Medical risk, temperament, quality of home environment, and developmental status were correlated with task measures of inattention and impulsivity; developmental status and quality of home environment were correlated with examiner ratings of inattention, impulsivity, and hyperactivity during testing; and quality of home environment was correlated with parental reports of hyperactivity. Multiple regression analyses indicated that attention problems were predicted by temperament, environment, and the interaction between developmental status and quality of home environment. These findings support the usefulness of a multidimensional approach to the measurement of attention problems and a multivariate approach to prediction and suggest that quality of home environment, in interaction with characteristics of the infant, influences the development of self-regulation and attention among low birth weight children.

The changing panorama of cerebral palsy--bilateral spastic forms in particular

Our Swedish population-based cerebral palsy (CP) project started 25 years ago and today covers the birth years 1954-1990, with over 1400 CP cases. This large series (1, 2, 3) has opened new perspectives on time trends and aetiological background factors, where two areas of successively increasing knowledge stand out as particularly helpful. One is the growing amount of biological and clinical data from the continuously increasing cohorts of surviving very preterm infants, the other is the rapidly expanding and refined information from neuroimaging. Bilateral spastic CP (BSCP), including spastic and ataxic diplegia, tetraplegia and spastic-dyskinetic CP, is the most prevalent clinical group of CP syndromes, present in around 75% of preterm and 45% of term CP, and has shown the most significant prevalence changes over time. In this presentation we, therefore, focus on BSCP, also analysed in a collaborative study between southwest Germany and western Sweden and recently presented in a series of four papers (4, 5, 6, 7).

Hematopoietic growth factors: Part II

Anemia of prematurity (AOP) affects almost all infants that are born prematurely. Excessive phlebotomy in the NICU setting has exacerbated this condition. Until recently, erythrocyte transfusion has been the only therapy for AOP. Recombinant human erythropoietin (rh-EPO) has been shown to be effective in reducing erythrocyte transfusions in premature infants with AOP. Various studies have utilized rh-EPO as a treatment modality or as prophylaxis for AOP. The results of these studies have shown that rb-EPO is a complementary strategy along with restriction of phlebotomy and less liberal transfusion policies, to decreasing the number of transfusions that an infant may need. Trials are necessary to document the cost-effectiveness of rh-EPO as well as its long term effects on the premature infant.

Infantile hydrocephalus: management using CT assessment

When determining a management plan for infantile hydrocephalus, the determining factor for or against the implantation of a shunt is the degree of ventricular dilatation. The author has devised a standardised method of estimating this, the use of which has been shown to achieve consistently successful results. Dilatation was determined using the ventricular/biparietal (V/BP) ratio from the axial CT scan at the mid-portion of the bodies of the lateral ventricles, showing the greatest ventricular dilatation. According to this method, hydrocephalus was classified into four grades. These were mild (V/BP ratio 0.26-0.40), moderate (V/BP ratio 0.41-0.60), severe (V/BP ratio 0.61-0.90) and extreme (V/BP ratio 0.91-1). A V/BP ratio of less than 0.26 was considered normal. This method appeared to be accurate and reproducible in infants with hydrocephalus including those with asymmetrical and multiloculated ventricular dilatation. In all the patients with mild hydrocephalus, spontaneous regression or stabilisation occurred and their developmental outcome was normal. Patients with moderate and severe hydrocephalus needed a ventricular shunt and the developmental outcome was satisfactory in 87% of the cases. They were functionally normal although 18 had some abnormal neurological signs. In patients with extreme hydrocephalus the developmental outcome following shunting was satisfactory in 31% of the cases. They were functionally normal although four had abnormal neurological signs. This plan of management was used in a total of 144 infants and it proved to be highly successful.(ABSTRACT TRUNCATED AT 250 WORDS)

Neonatal encephalopathies as classified by EEG-sleep criteria: severity and timing based on clinical/pathologic correlations

Neonatal encephalopathies can be characterized in functional terms using electroencephalography. Severity of an encephalopathic state can also be estimated by electrographic interpretation independent of the time of disease process onset. Moderately or markedly abnormal electroencephalographic patterns on serial studies are highly correlated with neurologic sequelae in survivors. Electroencephalography is rarely pathognomonic or specific in determining when a condition initially occurred. However, electroencephalographic abnormalities are associated with different clinical situations, and brain lesions documented on neuroimaging or with postmortem neuropathologic examination are observed in infants with certain abnormal electrographic patterns. When interpreted in the context of history, clinical findings, and other laboratory information, the neurophysiologic studies augment the understanding of both the severity and timing of an encephalopathic state.

Evaluation of diagnostic criteria of acute renal failure in premature infants

A prospective study was performed to investigate the validity of renal failure index (RFI) or fractional excretion of sodium (FENa) in preterm infants. The subjects were 128 newborn infants, 72 with oliguria and 56 without renal dysfunction (control). Oliguric infants were divided into two categories: acute renal failure (ARF) and prerenal failure (PRF), according to creatinine clearance (Ccr). Furthermore, all subjects were divided into four groups according to gestation, that is, 38 infants with gestational age of 25-28 weeks (group 1), 28 with 29-30 weeks (group 2), 38 with 31-36 weeks (group 3) and 24 of > 37 weeks (group 4). As a result, differentiation between ARF and PRF was valid when the RFI or FENa was used in infants of > 29 weeks gestation (groups 2, 3 and 4). Although infants of > 31 weeks gestation (groups 3 and 4) who present with an RFI > 3 or an FENa > 3% may be diagnosed as having ARF, infants in group 2 with an RFI of > 8 or an FENa of > 6% may be diagnosed as having ARF. For the infants in group 1, the application of RFI or FENa for diagnosis of ARF may be limited because of some overlap among the groups.

Screening for retinopathy of prematurity

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Standardised method of follow-up assessment of preterm infants at the age of 5 years: use of the WHO classification of impairments, disabilities and handicaps. Report from the collaborative Project on Preterm and Small for gestational age infants (POPS) in The Netherlands, 1983

A nationwide, prospective study was initiated in The Netherlands in 1983, involving 1338 liveborn infants with a gestational age less than 32 weeks and/or a birthweight less than 1500 g. Pre- and perinatal data, methods and results of follow-up until the corrected age of 2 years have been published previously. In this paper, methods of follow-up at the age of 5 years are described. At that age, 966 children were alive, of which 927 (96%) were assessed during a home visit 2 to 6 weeks after their fifth birthday by three specially trained paediatricians. A questionnaire served to collect data on medical history, respiratory function, behaviour and socio-economic factors. Standardised tests were carried out covering the following 10 areas: congenital malformations, neuromotor function, mental development, hearing, visual function, language and speech development, behaviour, musculoskeletal system, respiratory tract and ENT problems, and growth. The outcome was recorded for separate areas and for the child as a whole using the WHO classification of impairments, disabilities and handicaps.

[Prevention of hemorrhagic cerebral injury in newborn and premature infants subjected to mechanical ventilation]

The newborn brain, and even more so the brain of the premature child, can be considered as an authentic target organ for numerous pathological conditions, some of which exist outside the central nervous system (changes involving primarily both respiratory function and cardiocirculatory function with serious repercussions at encephalic level). In the premature, this greater "vulnerability" is related to the reduced or absent capacity for self-regulation of the cerebral blood low (mechanism influenced negatively by hypoxia, hypercapnia and metabolic acidosis conditions) and the important role played by numerous factors in protecting newborns from haemorrhagic damage. Of these the most important are the state of prematurity, the presence of vascular, intravascular and extravascular changes, the effects exerted on cerebral haemodynamics by mechanical ventilation and by certain drugs employed in treatment. In mechanically ventilated newborns and premature, prevention of haemorrhagic damage (periendoventricular) is currently based on the application of clear-cut protocols of intensive and rehabilitative treatment. The following form part of these protocols: low damage ventilation techniques (high frequencies, low PJP, low MAP), curarisation (to avoid fluctuations in cerebral blood flow), neuroprotection (phenobarbital), the use of substances and drugs which, by exploiting different mechanisms, go to reduce the extent of the haemorrhage (vitamin E, indomethacin, ethamosylate, tranexamic acid).(ABSTRACT TRUNCATED AT 250 WORDS)

Neonatal hypoglycaemia--the controversy regarding definition

Major paediatric textbooks and the views of neonatologists in the United Kingdom were surveyed to establish a definition of neonatal hypoglycaemia. The definition ranged from a glucose concentration of less than 1 mmol/l to less than 4 mmol/l. Hypoglycaemia is recognised to cause neurological sequelae and yet there is no accepted definition of the lower limit of normality for circulating blood glucose concentrations.

Cervical teratomas: an analysis. Literature review and proposed classification

Cervical teratomas are uncommon lesions usually diagnosed at birth but occasionally reported in older children and adults. During a 58-year span, nine cervical teratomas were identified at our institution (four previously reported): three stillborns with giant tumors; five live newborns; and one adult with a malignant tumor. Of the five newborns, two prematures died within one hour of birth. Of the three survivors, 2 had respiratory distress at birth. These infants were treated with early excision and are well at 7, 6, and 2 years of age. The last patient also had cystic fibrosis. The adult died of metastatic disease 8 months after resection. A literature review disclosed 212 cases in addition to the five reported here. Previous attempts at categorizing cervical teratomas have failed to address clinical patterns and have little prognostic value. We propose a classification based on birth status, age at diagnosis, and the presence or absence of respiratory distress. Group I--stillborn and moribund live newborns: number (N), 27; mortality (M), 100%. Group II--newborn with respiratory distress: N, 99; M, 43.4%. Group III--newborn without respiratory distress: N, 37; M, 2.7%. Group IV--children age 1 month to 18 years: N, 31; M, 3.2%. Group V--adults: N, 23; M, 43.5%. Twenty-six patients in group II and one in group III died without excision of the mass. Seventy-three patients in group II, 36 in group III, and 31 in group IV had extirpation of the tumor. Operative mortality was 11%, 0%, and 3.2%, respectively.(ABSTRACT TRUNCATED AT 250 WORDS)

A developmental study on types and frequency distribution of short apneas (3 to 15 seconds) in term and preterm infants

We measured the frequency distribution and the ventilatory correlates of the various types of apneas 3 to 15 s long during sleep in eight term infants (birth weight 3.65 +/- 0.16 kg; gestational age 39.5 +/- 0.3 wk) and eight preterm infants (birth weight 2.07 +/- 0.18 kg; gestational age 34.3 +/- 0.4 wk). Each infant was studied on five to seven occasions from birth to 56 wk of postconceptual age using a modified flow-through system. Sixty-six paired epochs of quiet sleep (1163 min) and rapid eye movement sleep (829 min) were analyzed in term infants and 85 paired epochs of quiet sleep (1553 min) and rapid eye movement sleep (1328 min) in preterm infants. Of the 783 apneas recorded in term infants 82% were central, 1.5% obstructive, 0.5% mixed, and 16% were of the breath-holding type; the corresponding figures for the 4086 apneas recorded in preterm infants were 93, 0.5, 1.0, and 5.5%. This distribution was similar in the two sleep states but term infants had a higher percentage of breath-holding apneas than preterm infants (p less than 0.01). In preterm infants the rate of central apneas decreased with postnatal age (p less than 0.01); in term infants the rate did not change significantly. The duration of apneas showed a modal distribution for central apneas at about 8 s for both groups during the 1st month of life (p less than 0.05). The findings suggest: 1) apneas in the newborn and early infancy are primarily central and are more frequent in preterm than in term infants.(ABSTRACT TRUNCATED AT 250 WORDS)

Frequency and cost of diagnosis-related group outliers among newborns

Analysis of outliers, as defined by the Health Care Financing Administration, among 47,776 newborns discharged from 33 short-term hospitals in Maryland in 1981 shows that the three prematurity diagnosis-related groups (DRGs) (386 to 388) represented only 5.3% of all discharges of newborns, but more than one fifth of all outliers and more than three fifths of outlier days of care for newborns. The disparity in charges for outliers and inliers (not exceeding the "trim point") is even more dramatic. Newborns with "extreme immaturity" (DRG 386) and "prematurity with major problems" (DRG 387) together accounted for less than 3% of all newborn discharges but for nearly one fourth of all outlier discharges. The mean length of stay in hospitals for outliers in those two DRGs was more than 2 months. The mean charge per outlier discharge in DRG 386 was $27,061 in 1981. Nearly one third of the discharges and more than two thirds of the days of care in this DRG were for outliers. Outliers occurred up to five times more often among premature neonates than among normal newborns and occurred preponderantly in teaching hospitals, especially those with more than 400 beds. This finding may require a reevaluation of the outlier trim points and the reimbursement method for newborn DRGs to assure adequate payment to the providers of neonatal intensive care, mainly large teaching hospitals.

Electroencephalographic study of intraventricular hemorrhage in the preterm newborn

The neonatal EEG was studied in 19 preterm infants with peri- and intraventricular hemorrhage (IVH) verified by CT scan. The background EEG showed an increasing discontinuity with increasing severity of brain damage. The EEG was of little diagnostic value but provided a good prognostic tool. The degree of brain damage classified by background EEG was significantly correlated with clinical outcome, but the degree of hemorrhage graded by CT scan was of less prognostic value. Positive rolandic sharp waves were seen in only 2 of 19 infants and were of little diagnostic significance. The EEG was also useful to detect subtle seizures including apneic ones in very low-birthweight infants with IVH.