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Neo Abstracts
Amedeo neonatology 09 Marzo 2004
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1: Maternal and neonatal factors and mortality in children with Down syndrome born in 1973-1980 and 1995-
1998. Acta Paediatr. 2004 Jan;93(1):106-12. Frid Cet cols Unit of Paediatrics, Department of Women's and
Children's Health, Uppsala University, Uppsala, Sweden
AIMS: To investigate maternal and neonatal factors in Down syndrome (DS) at birth, the impact of a congenital heart defect (CHD) on these factors and changes over time. METHODS: Medical data of children with DS born in northern Sweden in the periods 1973-1980 (n = 219) and 1995-1998 (n = 88) obtained from the Swedish Medical Birth Register were compared. A comparison with the general population on a group level was also made. RESULTS: The main finding was a reduction in infant mortality in DS, from 14.2% to 2.3% in 1995-1998 (p < 0.001), but this was still significantly higher than in the general population. The rate of Caesarean sections increased over time (from 14.5% to 27.3%, p < 0.05) even after adjustment for increased maternal age. No change over time was detected in the following rates: premature birth (gestational age < or = 36) (25%); asphyxia (5-min Apgar score < or = 6) (8%); low birthweight (< 2500 g) (14%); or small for gestational age (SGA) (14%); all rates were significantly higher than those of the general population. A CHD did not seem to influence the rates of these factors in a logistic regression model. CONCLUSION: Infant mortality decreased substantially over time in the DS group, whereas there was no reduction in the rate of asphyxia, SGA, low birthweight or prematurity. The presence of a CHD did not influence any of the neonatal factors studied.
2.- Low prevalence of complications of delayed herniotomy in the extremely premature infant.
Acta Paediatr. 2004 Jan;93(1):94-8. Gonzalez Santacruz M, Neonatal Unit, Department of Paediatrics, Hospital General Universitario de Alicante, Alicante, Spain.
AIM: To study the relationship between the delay of herniotomy in the extremely premature infant and the rate of complications in comparison with full-term children. METHODS: A follow-up study of three groups of neonates operated on for inguinal hernia was performed. The groups were defined as: a) the short-waiting group (SWG): prematures (mean gestational age: 32.56 +/- 0.62; n = 9) operated on within 2 wk of diagnosis (median: 5 d); b) the long-waiting group (LWG): prematures (mean gestational age: 28.38 +/- 1; n = 21) operated on after more than 2 wk (median: 39 d); and c) control group of full-term children (FTG); (mean gestational age: 38.18 +/- 0.29; median of timing: 3 d; n = 11). Several variables (gestational age, weight at birth and at surgery, side of the inguinal herrnia, timing, duration of surgery, type of anaesthesia, length of hospitalization), as well as the occurrence of apnoea, incarceration and testicular atrophy were compared between groups. RESULTS: Timing was the only variable that was different between the LWG and the other two groups (p < 0.001, ANOVA). Seven preoperative episodes of incarceration occurred: one in the SWG, two in the LWG and four in the FTG (p = 0.138, chi2). In the follow-up study two testicular atrophies, related to previous episodes of incarceration, were found: one in the FTG and the other in the SWG (p = 0.221, chi2). CONCLUSION: The deferral of herniotomy in the extremely premature infant, until the child is ready to be discharged from the neonatal unit, does not seem to increase the risk of incarceration episodes or testicular atrophy.
3.- Diagnosis and management of gastro-oesophageal reflux in preterm infants in neonatal intensive care units. Acta Paediatr. 2004 Jan;93(1):88-93. Dhillon AS . Department of Neonatology, Birmingham Women's Hospital, Edgbaston, Birmingham, UK.
AIM: There is relatively
little published information regarding gastro-oesophageal reflux (GOR) in
preterm infants, therefore the aim of this study was to elucidate the
incidence of GOR and management regimes employed for this condition in major
neonatal intensive care units (NICUs). METHODS: A standard questionnaire was
sent to consultants in 77 level II (or secondary) and III (or tertiary) NICUs.
RESULTS: Seventy-eight percent of consultants responded. Of babies born in
these units, 40% were less than 34 wk gestational age and the estimated
incidence of GOR in this group was 22%. GOR was diagnosed on a clinical basis
alone in 42% of units, 8% used clinical features and/or investigations, and
50% used clinical features plus investigations and/or therapeutic trials.
Intra-oesophageal pH monitoring was available in 93% of units but used
regularly in only 32% of suspected cases. Common treatment strategies for
diagnosed GOR included non-drug options--body positioning (98%) and placement
on a slope (96%); and drugs--H2-receptor antagonists (100%), feed thickeners
(98%), antacids (96%), prokinetic agents (79%), proton-pump inhibitors (65%)
and dopamine-receptor antagonists (53%). However, the frequency with which all
of these treatments were used varied widely between units. Surgery was
required in only 1% of cases. CONCLUSIONS: GOR is perceived to be a common
condition in preterm infants but the lack of published evidence relating to
the management of GOR in preterm infants is reflected in the wide variation in
diagnostic and treatment strategies used in major NICUs. It is clear that
randomized, controlled trials to evaluate appropriate and effective treatments
are needed.
AIM: To examine the process of change in hearing threshold during the neonatal period after perinatal hypoxia-ischaemia. METHODS: The threshold of brainstem auditory evoked responses (BAER) was measured serially during the first month after birth in 92 term babies who suffered hypoxia-ischaemia. RESULTS: The mean BAER threshold in these babies was significantly increased on day 1 (ANOVA p < 0.001). The elevated threshold decreased progressively on days 3 and 5, but was still significantly higher than that in normal controls (p < 0.01). The elevation continuously decreased more slowly on days 10 and 15, and to a near normal level on day 30. Threshold elevation was seen in 31.7% of the babies on day 1, and 34.5% during the first three days. The rate of elevation decreased progressively thereafter. On day 30, 10.6% of the subjects still had increased thresholds. Moderate to severe elevation occurred mainly during the first week and severe elevation occurred predominately on day 1. Threshold elevation starting after days 3-5 is likely to be due to middle-ear disorders. As a whole, during the first month, 44.6% (41/92) of the babies studied had threshold elevation. BAER threshold was correlated weakly with the stage of hypoxic-ischaemic encephalopathy on days 1 and 3. The threshold was significantly higher in babies with severe encephalopathy than in those with mild or moderate encephalopathy during the first 3 d of life. CONCLUSION: Hearing threshold is elevated in about one-third of term babies after hypoxia-ischaemia. The elevated threshold decreases progressively after birth, and returns to normal by one month in most babies. The threshold correlates weakly with the severity of encephalopathy.
AIM: To clarify further
the influence of intrauterine growth retardation (IUGR) on early neural
development. METHODS: In 30 small-for-gestational age (SGA) preterm infants at
term, brainstem auditory-evoked responses (BAERs) were recorded with clicks of
different repetition rates. All infants had a birthweight < 3rd centile,
without any other major perinatal complications. RESULTS: Compared with the
BAER in 36 appropriate-for-gestational age (AGA) term infants, the preterm SGA
infants did not show any abnormalities at 21 s(-1) clicks, except for a slight
increase in wave III amplitude. At 51 s(-1) clicks, there was an increase in
III-V/I-III interval ratio (ANOVA p < 0.05). At 91 s(-1), the I-III interval
shortened, whereas the III-V interval and III-V/I-III interval ratio increased
(all p < 0.05). Wave V amplitude tended to increase slightly at all repetition
rates of clicks used, although this increase did not reach statistical
significance. The III-V interval and III-V/I-III interval ratio in the preterm
SGA infants at different click rates correlated inversely with occipitofrontal
head circumference at the time of testing, i.e. the smaller the head the
longer the III-V interval (all p < 0.01). Wave III amplitude at 21 s(-1) also
correlated inversely with head circumference (p < 0.01), suggesting that the
slight increase in this amplitude in the preterm SGA infants is related to
their relatively small head size. CONCLUSION: There were no major
abnormalities in the BAER up to 91 s(-1) clicks at term in preterm SGA infants.
The slight increase in III-V interval at high-rate stimulation suggests a
subtle degree of central neural dysfunction, which is associated with small
head size following IUGR.
AIM: Measurement of cerebral haemodynamics to detect impaired cerebral blood flow and impaired cerebral autoregulation might make prevention of brain lesions and especially periventricular leucencephalomalacia (PVL) achievable. METHODS: Changes in cerebral blood volume (CBV) and the cerebral haemoglobin oxygenation index (cHbD) following tilting up and down in 10 preterm infants with PVL and 25 preterm infants without PVL, measured by near infrared spectroscopy (NIRS), were analysed. Tilting manoeuvres were recorded with a polysomnographic system in combination with NIRS. CBV and cHbD of the baseline phase (1 min before tilting) were compared with data from the post-tilting phase (1 min after tilting). RESULTS: Changes in CBV and cHbD after tilting were significantly pronounced in infants with PVL compared with infants without PVL. CBV decreased in infants with PVL, by -0.099 +/- 0.081 ml 100 g(-1) brain (mean +/- SD) after tilting up, and increased by 0.106 +/- 0.104 ml 100 g(-1) brain after tilting down. CBV decreased in infants without PVL, by -0.041 +/- 0.068 ml 100 g(-1) brain after tilting up, and increased by 0.020 +/- 0.096 ml 100 g(-1) brain after tilting down. cHbD showed similar changes after tilting. CONCLUSION: Changes in CBV and cHbD after tilting were pronounced in preterm infants with PVL and this may indicate reduced cerebral autoregulatory capacity.
AIM: Inhaled nitric oxide (iNO) is used to reduce right-to-left extrapulmonary shunting by decreasing pulmonary vascular resistance in term or near-term infants. The objectives of this study were to determine, first, the pulmonary blood flow status of very preterm infants with hypoxaemic respiratory failure, then the response of oxygenation to iNO therapy according to pulmonary blood flow (PBF) and, finally, to verify the lack of adverse side effects of iNO on the ductus arteriosus. METHODS: Infants below 32 wk gestational age (GA) with hypoxic respiratory failure and aAO2 < 0.22 were randomized as the control or iNO group. PBF was evaluated by pulsed Doppler measurement of mean pulmonary blood flow velocity (MPBFV) in the left pulmonary artery. Low PBF (LPBF) was defined as MPBFV < 0.2 m/s. RESULTS: Seventy infants of 23 to 31 wk GA with hypoxic respiratory failure were randomized either to receive or not to receive 5 ppm iNO in addition to optimal care. Twenty-eight infants were diagnosed with LPBF (11/35 in iNO vs 17/35 in the control groups). Thirty minutes after receiving iNO the number of LPBF infants dropped to 8/35. In the iNO group, aAO2 increased significantly from 0.14 +/- 0.05 to 0.24 +/- 0.08 after iNO, but only in the LPBF infants (mean +/- SD; p = 0.027). CONCLUSION: In infants below 32 wk GA with hypoxic respiratory failure, Doppler echocardiographic assessment of LPBF seems to be able to determine which patients are likely to benefit from iNO therapy on systemic oxygenation.
Early observations emphasized the possible development of hyponatraemia in hypothyroid children and adults, but recently this has been questioned. AIM: To investigate whether hyponatraemia develops in hypothyroid status by examining sodium handling in screening-detected neonates and infants with congenital hypothyroidism (CH). METHODS: Serum thyroid-stimulating hormone (TSH), free thyroxine (FT4), sodium (Na), creatinine (Cr), urinary Na, Cr, fractional sodium excretion rate (FENa) and other chemicals were measured before and after L-thyroxine (LT4) replacement therapy in 32 screening-detected CH neonates (11M, 21F) and 16 age-matched control neonates. RESULTS: No cases of hyponatraemia were found in the 32 CH neonates. Their serum Na concentrations (139.1 +/- 1.5 mmol/L, ranging from 136 to 142 mmol/L, median 139 mmol/L) were not statistically different from those of 16 control neonates (139.3 +/- 1.3 mmol/L, ranging from 137 to 142 mmol/L, median 139 mmol/L). No correlation was found between serum levels of TSH and FT4 and serum Na or FENa. No significant changes were found in serum Na concentrations in hypothyroid neonates two months after LT4 replacement therapy. The serum Na concentration (139.1 +/- 0.3 mmol/L, n = 25) before treatment did not change statistically (138.9 +/- 0.2 mmol/L, n = 25) two months after LT4 replacement therapy. CONCLUSION: As seen in various earlier reports, hyponatraemia can occur in hypothyroid patients, but no causal relationship exists between them. When hyponatraemia is detected in hypothyroid children, it does not seem to be directly related to lack of thyroid hormones and therefore other possible causes should be sought.
9.- Orphaned and vulnerable to infection, undernutrition and early death: increasing threats to infants and children. Acta Paediatr. 2004 Jan;93(1):8-9. Gracey M. School of Public Health, Curtin University, Perth, Western Australia.
Infants and young children in Guinea-Bissau who were made motherless had much higher mortality rates than a control group of subjects. Child mortality was higher in rural than urban children and was highest under 2 y of age and within 6 mo of their mothers' deaths. The authors of this study, which appears elsewhere in this issue, suggest that premature weaning may contribute to this excess mortality. CONCLUSION: There are many causes of maternal mortality that can lead to motherlessness among infants and children, particularly in developing countries. Multifaceted approaches to the care of these children are needed to lessen their excessive mortality. Paediatricians have a potentially very important role in preventing this burden of childhood ill-health and deaths.
The case is reported of a seriously affected newborn with homozygous protein C deficiency who developed neonatal purpura fulminans. Foetal ultrasound at 33 wk of gestation revealed ventriculomegaly. The first lesions appeared on the scalp 48 h after birth. She was initially treated with fresh-frozen plasma and, after the diagnosis was confirmed, with purified protein C concentrate. After skin necrosis had healed, therapy was continued with oral warfarin. The infant was homozygous for protein C W380G mutation. Diagnosis at the DNA level gave the parents an option of reliable prenatal diagnosis in their subsequent pregnancy. CONCLUSION: Difficulties in reaching an accurate diagnosis are discussed since early diagnosis and urgent therapy with protein C replacement are crucial to avoid further damage after delivery.
AIM: To compare three different schedules in severe meconium aspiration syndrome (MAS) treatment: standard, bronchoalveolar lavage (BAL) with diluted surfactant, and diluted surfactant BAL plus a single early dexamethasone dose. METHODS: Twenty-four full-term newborns with severe MAS (needing mechanical ventilation and with oxygenation index > or = 15) were divided into three groups: group I (historical control group; n = 6) treated with standard therapy; group II (n = 7) treated in the first hours of life with one BAL using diluted surfactant (beractant 5 mg/mL) in a volume of 15 mL/kg in four aliquots; and group III (n = 11) treated with one diluted surfactant BAL and a previous single dose of intravenous dexamethasone (0.5 mg/kg). RESULTS: At 12 h, groups II and III showed a significant improvement in oxygenation index (OI) compared with group I (14.7% and 27.0% vs -19.6% respectively; p = 0.012). Group III also showed a significantly lower OI than group I at 24 h (63.6% vs -27.9%) and at 48 h (87.1% vs 49.6%). Group III, in comparison to group I, showed a lower FiO2 requirement at 12 h (0.66 vs 1), at 24 h (0.4 vs 0.87) and at 48 h (0.35 vs 0.67), and a decrease in the number of days of inhaled nitric oxide administration, mechanical ventilation, oxygen therapy and hospitalisation period. All patients from groups II and III survived and none developed pneumothorax or respiratory infections. CONCLUSION: Diluted surfactant BAL in the first hours of life combined with an intravenous single dose of dexamethasone may be an effective treatment for severe MAS.
AIM: To evaluate the Apgar score predictive power for mortality during different periods in the first year of life in a population with a very low mortality rate. METHODS: The records of all singleton live births without severe congenital malformations and length of gestation >25 wk (n = 976635) were collected from the Swedish Medical Birth Registry, 1990 to 1998. Receiver operating characteristic (ROC) analysis was utilized. RESULTS: Both the 1-min and the 5-min Apgar scores were shown to be good discriminators for early mortality, with the area under the ROC curve >0.85. For babies at risk of early death, the selected cut-off values for the 1-min Apgar score was <8 for preterm (true-positive (TP) rate: 83.9%; false-positive (FP) rate: 17.7%) and term babies (TP rate: 69.4%; FP rate: 6.7%). At 5 min, the analysis revealed that newborns with an Apgar score <9 were at risk for early death (preterm babies: TP rate: 79.8%; FP rate: 13.3%; term babies: TP rate: 73.8%; FP rate: 3.4%). CONCLUSIONS: Our analysis did not support the common practice in the clinic or in research of grouping infants at risk in Apgar score groups, i.e. a score below 4 or a score below 7. However, the data presented here allow the clinicians and researchers to identify and define a suitable cut-off point in relation to the quality of neonatal care and resources available, rather than adhering to a historical cut-off value that has not been studied in depth.
Corticosteroid treatment in severe meconium aspiration syndrome may afford, especially if started early, some improvement in oxygenation, lung function and pulmonary haemodynamics during the acute phase of the disorder. Still, the effects of corticosteroids on lung tissue perturbations and outcome of diseased infants remain unclear. CONCLUSION: Further research is needed to determine the clinical significance and optimal timing and dosing of corticosteroid treatment in severe meconium aspiration syndrome.
We report a case of idiopathic hypereosinophilic syndrome in a young child with favorable outcome after treatment with alpha-interferon. Case report. - A 5-month-old boy presented with major eosinophilia (187 G/l) associated with splenomegaly. There was no evidence for parasitic or allergic disease. Acute leukemia was suspected but bone marrow smear and medullary caryotype were not compatible. Idiopathic hypereosinophilic syndrome was thus diagnosed. Corticotherapy was started and failed. Finally, complete remission was obtained with alpha-interferon treatment. Conclusion. - Idiopathic hypereosinophilic syndrome is uncommon in children. Significant complications like cardiac dysfunction or hematologic malignancies can occur. Treatment has to be quickly started, in order to reduce eosinophilia. Haematological and echocardiographic follow-up are required.
15.-
We describe two cases of congenital varicella. The first presented with cutaneous aplasia and scars; the second with skin abnormalities, limb atrophy, limb paresis, Horner's syndrome and liver calcifications: prognosis was poor in this case. After reviewing the published cases of congenital varicella, we advocate the use of varicella vaccine in seronegative women before pregnancy.
Use of home oxygen therapy for prematurely born infants with chronic lung disease (CLD) can facilitate early discharge, but affected infants might require more readmissions. Our aim was to determine if health care utilisation and associated costs in the first 2 years were greater in centres with a high compared to centres with restricted use of home oxygen therapy. A retrospective review of the hospital and general practitioner (GP) medical records of 235 infants with CLD (median gestational age 27 weeks; range 22-33 weeks) was performed to note their readmissions, outpatient attendances, community service referrals and cost of care in the first 2 years after birth. A total of 76 infants (64%) in the high use centres and 12 (10%) in the restricted use centres were discharged home on oxygen. Infants in the high use centres were discharged home from neonatal care at a younger age (median 37.7 versus 39.9 weeks; P<0.001), but subsequently had similar numbers of inpatient events, and less GP ( P=0.012) and community care ( P<0.001) contacts, although their duration of home oxygen use was longer ( P<0.001). The post-discharge costs were similar in the two types of centre, but the neonatal costs ( P<0.0001) and total cost of care per infant over the first 2 years ( P<0.0001) were lower in the high use centres. CONCLUSION:early discharge and high use of home oxygen therapy was not associated with an increased cost of care or increased morbidity.
17.- Oesophageal pH monitoring and reflux oesophagitis in irritable infants. Eur J Pediatr. 2004 Mar 3 Vandenplas Y, Badriul H, Department of Paediatrics, Academic Children's Hospital, Free University of Brussels, Laarbeeklaan 101, 1090, Brussels, Belgium.
Acid reflux and/or oesophagitis may be responsible for inconsolable crying in infants. We evaluated prospectively the presence of acid reflux disease, oesophagitis and the accuracy of pH monitoring in the prediction of oesophagitis in a population of irritable infants. A 24-h oesophageal pH monitoring with a glass electrode and an upper gastro-intestinal tract endoscopy with grasp biopsies were performed in 60 irritable infants, aged 1 to 6 months, not responding to cow's milk elimination. The 24-h oesophageal pH monitoring was considered abnormal in 40/60 (66%) babies and histological oesophagitis was present in 26/60 (43%). In the infants with histological oesophagitis, the reflux index (% of the investigation time with a pH <4.0) was >5% in 18/26 (69%). Histology of the oesophagus was normal in 22 of the 40 (55%) infants with an abnormal pH monitoring. The mean reflux index in the group with oesophagitis (12.20%) was significantly higher than in the group with normal histology (8.74) ( P=0.036), although there was an important overlap. The sensitivity and specificity to predict oesophagitis with a reflux index of 5.0% or more was 69.2 and 35.3, respectively. There was not a reflux index which could be related to a clinically useful sensitivity and specificity to predict oesophagitis. CONCLUSION:acid gastro-oesophageal reflux disease and/or histological oesophagitis were diagnosed in 66% and 43% of irritable infants, respectively. There was no relation between symptoms and abnormal pH metry or oesophagitis; however, the reflux index does not accurately predict oesophagitis and normal histology does not accurately exclude acid gastro-oesophageal reflux disease. Oesophageal pH monitoring and endoscopy provide additional information.
18.- Nasal molding: A cultural practice causing respiratory distress in a term infant. J Pediatr. 2004 Mar;144(3):403-4. Murali H, Hurt H. Albert Einstein Medical Center and The Children's Hospital of Philadelphia, The Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania USA.
A case of respiratory distress secondary to the cultural practice of "nasal molding" is reported. Nasal molding should be included as an entity causing nasal obstruction without choanal atresia. Furthermore, this report underscores the role of interpreters in provision of health care.
19.- Aspiration of bile as a cause of respiratory distress in the newborn infant. J Pediatr. 2004 Mar;144(3):389-90 Ellison V, Lui K, Dargaville PA. Department of Neonatology, Royal Children's Hospital, Melbourne, the Department of Newborn Care, Royal Hospital for Women, Sydney, and Murdoch Children's Research Institute, Melbourne, Australia.
Early-onset respiratory
distress and a radiographic appearance of an aspiration syndrome occurred in
two neonates with gastroschisis who had evidence of inhalation of bile.
Hypoxemic respiratory failure developed in both infants, contributing to death
or prolonged respiratory morbidity. Bile aspiration syndrome should be
considered whenever there is early-onset respiratory distress in a neonate
with high intestinal obstruction.
20.- Effect of maternal antibody on immunogenicity of hepatitis A vaccine in infants. J Pediatr. 2004 Mar;144(3):327-32. Letson GW, Shapiro CN, Division of Viral Hepatitis, Centers for Disease Control and Prevention, Atlanta, Georgia USA.
OBJECTIVE: To determine the effect of maternal antibody on hepatitis A vaccine immunogenicity in infants.Study design Infants of mothers negative for antibody to hepatitis A virus (anti-HAV; group 1) were administered hepatitis A vaccine at 2, 4, and 6 months of age, and infants of anti-HAV-positive mothers were randomized to receive either hepatitis A vaccine (group 2) or hepatitis B vaccine (group 3) on the same schedule. Group 3 infants subsequently received hepatitis A vaccine at 8 and 10 months of age. RESULTS: At 15 months of age, 100% of infants in group 1, 93% in group 2, and 92% in group 3 had protective levels of antibody. However, there were significant differences in the geometric mean concentration (GMC) of anti-HAV between groups. Group 1 GMC was 231 mIU/mL, compared with 85 mIU/mL for group 2 and 84 mIU/mL for group 3 (P<.001, group 1 vs group 3). CONCLUSIONS: Passively acquired maternal anti-HAV resulted in a significantly lower final antibody response when infants were administered hepatitis A vaccine at 2, 4, and 6 months of age or at 8 and 10 months of age.
21.- Variation in childhood asthma among former preterm infants. J Pediatr. 2004 Mar;144(3):321-6 Grischkan J, Storfer-Isser A . Department of Pediatrics, Rainbow Babies and Children's Hospital, University Hospitals of Cleveland, Case Western Reserve University, Cleveland, Ohio, USA.
OBJECTIVES: The role of in utero and perinatal exposures in modifying asthma risk among children born prematurely was assessed.Study design Former preterm children (n=251) were identified from a birth cohort. Examinations, including lung function testing, were performed at ages 8 to 11 years. Perinatal exposures were ascertained from neonatal medical records. RESULTS: Univariate predictors of asthma included male gender, African American ethnicity, maternal asthma, and birth weight. Asthmatics were less likely to have been small for gestational age (SGA) than nonasthmatics (12.4% vs 22.7%, P=.04) and had more neonatal pulmonary disease. After adjusting for maternal asthma and demographic factors, asthma was associated with chronic lung disease of infancy, neonatal mechanical ventilation and corticosteroid use, and a higher childhood body mass index. Children who were septic postbirth and girls who were SGA were less likely to have asthma (OR for sepsis, 0.2; 95% CI, 0.1-0.6; OR for girls who were SGA compared with girls who were not SGA, 0.05; CI, 0.01-0.34). CONCLUSIONS: Among premature children, female SGA status and neonatal sepsis appear protective relative to the development of childhood asthma. Differential susceptibility to asthma among preterm children may relate to exposures that operate in the in utero and early postnatal environment to accelerate lung development, alter innate immunity, or both.
22.- Correlation of in situ detection of infectious agents in the placenta with neonatal outcome. J Pediatr. 2004 Mar;144(3):316-20. Genen L, Nuovo GJ, Department of Pediatrics, Winthrop University Hospital, SUNY Stony Brook School of Medicine, Mineola, New York USA.
OBJECTIVES: To determine if infections involving the placenta are associated with unexplained systemic illness in the newborn infant and subsequent poor neonatal outcome (death or significant neurodevelopmental abnormalities).Study design Placental tissue from 33 newborn infants with systemic illness and poor neonatal outcome were tested by in situ hybridization or reverse transcriptase-polymerase chain reaction for infectious pathogens. Control placentas came from mothers delivering infants with poor neonatal outcome of known cause (ie, cord prolapse, uterine rupture), mothers with known infections, and normal births (n=21). RESULTS: There were 5 deaths among the newborn infants, and all survivors had poor neonatal outcome. Placentas from 24 of 33 cases (73%) had positive test results for Coxsackie virus (46%), bacteria (38%), herpes (8%), and parvovirus (4%) and picornavirus (4%). At autopsy, multiple organs from the newborn infant had positive test results for the same organism isolated from the placenta. No infectious agents were detected in the control infants, except those from mothers with known infections. CONCLUSIONS: In utero infection of the placenta is associated with systemic illness in the newborn infant and poor neonatal outcome. These results emphasize the importance of pathologic and molecular examination of the placenta in critically ill newborn infants.
23.- Long-term outcome following extracorporeal membrane oxygenation for congenital diaphragmatic hernia: The UK experience.J Pediatr. 2004 Mar;144(3):309-315 Davis PJ, Firmin RK . Heartlink ECMO Centre, Glenfield Hospital, and the Department of Epidemiology, University of Leicester, Leicester, Great Ormond Street Hospital for Children, London, Royal Hospital for Sick Children, Yorkhill, Glasgow, Freeman Hospital, Newcastle-upon-Tyne, United Kingdom.
OBJECTIVE: We evaluated the long-term outcome of neonates receiving extracorporeal membrane oxygenation (ECMO) for congenital diaphragmatic hernia (CDH).Study design A retrospective review of all 73 neonates with CDH supported with ECMO in the United Kingdom between 1991 and 2000, with follow-up to January 2003. Information was from hospital charts and from communication with family doctors and pediatricians. Median follow-up period for survivors was 67 months. RESULTS: 46 infants (63%) were weaned from ECMO, 42 (58%) survived to hospital discharge, and 27 (37%) survived to age 1 year or more. A higher birth weight, higher 5-minute Apgar score, and postnatal diagnosis were "pre-ECMO" predictors of long-term survival. Comorbidity was common in long-term survivors: 13 (48%) had respiratory symptoms, 16(59%) had gastrointestinal problems, and 6 (19%) had severe neurodevelopmental problems. Only 7 children were free of significant neurodevelopmental deficit and required no further medical or surgical intervention. CONCLUSION: Using the current referral criteria, ECMO can be used to support the sickest neonates with CDH. However, there is significant mortality in the first year of life, and long-term physical and neurodevelopmental morbidity remains in the majority of survivors.
24.- A pilot investigation of mild hypothermia in neonates receiving extracorporeal membrane oxygenation (ECMO). J Pediatr. 2004 Mar;144(3):301-8. Horan M, Ichiba S. Department of Child Health, University of Leicester, and The HeartLink ECMO Centre, The Glenfield Hospital, Leicester, and the Department of Paediatrics, Imperial College School of Medicine, London United Kingdom.
OBJECTIVE: To
investigate the safety and feasibility of using mild hypothermia in neonates
receiving extracorporeal membrane oxygenation (ECMO).Study design A
prospective, nonrandomized pilot study of 25 neonates referred for ECMO. Whole
body cooling was achieved by adjustment of the temperature of the
extracorporeal circuit water bath. Five groups (N=5 per group) were each
studied for the first 5 days of ECMO. The first group was maintained at 37
degrees C throughout the study period. Subsequent groups were cooled to 36
degrees C, to 35 degrees C, and, finally, to 34 degrees C, respectively, for
24 hours and the final group to 34 degrees C for 48 hours before being
rewarmed to 37 degrees C. Patients were carefully assessed clinically and
biologically. In addition to routine laboratory tests, cytokines (IL-6 and
IL-8), complement (C3a), and molecular markers of coagulation (thrombin/antithrombin
III [TAT], antithrombin III, and plasmin-alpha2plasminogen) were measured.
RESULTS: No major clinical or circuit problems were noted during cooling or
rewarming. In particular, there were no problems of bleeding or cardiac
arrhythmia. No significant difference was found between groups in terms of
molecular markers of coagulation, complement, cytokines, and platelet
transfusions. CONCLUSIONS: Applying mild hypothermia (34 degrees C) for 24 or
48 hours to neonates receiving ECMO is both feasible and safe.
25.- Dexamethasone therapy in neonates treated with extracorporeal membrane oxygenation. J Pediatr. 2004 Mar;144(3):296-300 Griffin MP, Wooldridge P, Alford BA, McIlhenny J, Ksenich RA. Departments of Pediatrics and Radiology, University of Virginia Health System, Charlottesville, Virginia USA.
OBJECTIVE: To test the hypothesis that infants who received dexamethasone would have a shorter length of time on extracorporeal membrane oxygenation (ECMO).Study design Infants placed on ECMO for respiratory failure were randomly assigned to receive either dexamethasone for 3 days or placebo. Chest radiographs were scored through the use of a validated standard scoring system to assess lung injury. RESULTS: Thirty infants received dexamethasone and 29 received placebo. The median (25th%, 75th%) duration of time on ECMO was 143.5 (100, 313) hours in the dexamethasone group and 160 (111, 303) hours in the placebo group (not significant). Survival was 80% in the dexamethasone group and 83% in the placebo group. Radiographic lung injury scores (mean+/-SEM) were significantly improved in the dexamethasone group (10.5+/-0.6) versus placebo (12.3+/-0.5) on day 3 of ECMO (P=.013). Hypertension developed in 27 of the 30 infants receiving dexamethasone and 13 of the 29 infants in the placebo group during ECMO (P<.01). CONCLUSIONS: Dexamethasone given during the first 3 days of ECMO results in significant improvement in lung injury scores by day 3 of ECMO but does not significantly decrease the duration of ECMO or improve survival. The preponderance of evidence would not support the use of dexamethasone in this setting.
26.- Relationship of the ventilatory response to hypoxia with neonatal apnea in preterm infants. J Pediatr. 2004 Mar;144(3):291-5. Nock ML, Difiore JM, Department of Pediatrics, Division of Neonatology, Rainbow Babies and Children's Hospital, Case Western Reserve University, Cleveland, Ohio, USA.
OBJECTIVE: Correlate the
ventilatory response of preterm infants to hypoxic exposure with incidence of
neonatal apnea.Study design Seventeen stable convalescing premature infants
underwent bedside cardiorespiratory monitoring of respiration using
respiratory inductance plethysmography, heart rate, and oxygen saturation (SaO(2))
for a 12-hour period. These studies were scored for number of apneas >/=15 and
>/=20 seconds. Infants then underwent a 3-minute hypoxic exposure. Minute
ventilation (V(E)) was calculated for 30-second epochs from the time inspired
oxygen reached 15%. Linear regression analysis was used to correlate the
change in V(E) normalized for decrease in SaO(2) (DeltaV(E)/DeltaSaO(2))
during the first and third minutes of hypoxic exposure with the number of
apneic episodes during the 12-hour study. RESULTS: The majority of infants
exhibited an anticipated biphasic ventilatory response to hypoxia. There was a
significant positive correlation between DeltaV(E)/DeltaSaO(2) during the
first and third minutes of hypoxic exposure and number of apneic episodes
>/=15 and >/=20 seconds during the preceding 12 hours. CONCLUSIONS: Preterm
infants with a greater number of apneic episodes exhibit an increased
ventilatory response to hypoxic exposure, suggesting that apnea of prematurity
may be associated with enhanced peripheral chemoreceptor activity.
27.- Clinical use of the Neonatal Intensive Care Unit Network Neurobehavioral Scale. Pediatrics. 2004 Mar;113(3 Pt 2):679-89 Boukydis CF, Palmer Institute, Wayne State University, Detroit, Michigan 48202, USA.
Features of the Neonatal Intensive Care Unit Network Neurobehavioral Scale that make the examination useful for clinical application are described. Clinical applications in various settings and populations are described. This is followed by a summary of the clinical significance of the examination according to the packages of administration. We then explain how to use the summary scores clinically, writing a clinical summary and the clinical interpretation of the summary scores. Finally, we present a case study with a clinical summary and a work sheet that clinicians may find useful for clinical consultation with caregivers and parents.
28.- Summary statistics of neonatal intensive care unit network neurobehavioral scale scores from the maternal lifestyle study: a quasinormative sample. Pediatrics. 2004 Mar;113(3 Pt 2):668-75. Lester BM, Tronick EZ, LaGasse L, Seifer R, Brown Medical School, Infant Development Center, Women and Infants Hospital and Bradley Hospital, Providence, Rhode Island 02903, USA.
Descriptive statistics
for the Neonatal Intensive Care Unit Network Neurobehavioral Scale summary
scores are provided based on data from 1388 1-month-old infants in the
Maternal Lifestyle Study (MLS) of prenatal drug exposure and child outcome.
The multisite MLS is described, followed by tables with descriptive statistics
and percentile for the Neonatal Intensive Care Unit Network Neurobehavioral
Scale summary scores. The tables include data for the entire MLS sample as
well as tables by drug exposure status, gestational age, poverty status, sex,
race and ethnicity, and MLS study site. These tables can be used as quasinorms
for comparison with other infants of this age.
29.- The Neonatal Intensive Care Unit Network Neurobehavioral Scale procedures. Pediatrics. 2004 Mar;113(3 Pt 2):641-67. Lester BM, Tronick EZ, Brazelton TB. Brown Medical School, Infant Development Center, Women and Infants Hospital and Bradley Hospital, Providence, Rhode Island 02903, USA.
The procedures for the
Neonatal Intensive Care Unit Network Neurobehavioral Scale includes a brief
background, description of the examination, key concepts, a summary of the
procedures, and order of administration of the items described in "packages,"
information about the testing kit, scoring issues, and summary scores. This is
followed by presentation of the 115 items that are scored. Each item is
described, including (where appropriate) specific procedures for how to
manipulate or handle the infant. Rating scales with scoring criteria are
provided for each item. With training and certification, users of the manual
will be able to reliably administer and score the Neonatal Intensive Care Unit
Network Neurobehavioral Scale.
30.- History and description of the Neonatal Intensive Care Unit Network Neurobehavioral Scale. Pediatrics. 2004 Mar;113(3 Pt 2):634-40. Lester BM, Tronick EZ. Brown Medical School, Infant Development Center, Women and Infants Hospital, Providence, Rhode Island 02903, USA.
This article provides an introduction and background to the Neonatal Intensive Care Unit Network Neurobehavioral Scale (NNNS). First is a summary of the history of the field of infant assessment. This is followed by a description of the NNNS, including its basic features and how the NNNS differs from other examinations. We then describe the biobehavioral basis for the examination and review studies in which the NNNS has been used. Finally we discuss the developmental model on which the NNNS is based and consider the implications of using the examination.
31.- Prevalence and correlates of successful transfer from pediatric to adult health care among a cohort of young adults with complex congenital heart defects. Pediatrics. 2004 Mar;113(3 Pt 1):e197-205. Reid GJ, Irvine MJ, Department of Psychology and Family Medicine, University of Western Ontario, London, Ontario, Canada.
OBJECTIVES: More than
85% of children born today with chronic medical conditions will live to
adulthood, and many should transfer from pediatric to adult health care. The
numbers of adults with congenital heart defects (CHDs) are increasing rapidly.
Current guidelines recommend that just over half of adult CHD patients should
be seen every 12 to 24 months by a cardiologist with specific CHD expertise at
a regional CHD center, because they are at risk for serious complications (eg,
reoperation and/or arrhythmias) and premature mortality. The present study
aimed to determine the percent of young adults with CHDs who successfully
transferred from pediatric to adult care and examine correlates of successful
transfer. DESIGN: Cross-sectional study with prevalence data from an entire
cohort. SETTING AND PATIENTS: All patients (n = 360) aged 19 to 21 years with
complex CHDs who, according to current practice guidelines, should be seen
annually at a specialized adult CHD center were identified from the database
of the cardiology program at the Hospital for Sick Children in Toronto, Canada,
a pediatric tertiary care center. Of these patients, 234 completed measures
about health beliefs, health behaviors, and medical care since age 18 years.
MAIN OUTCOME MEASURE: All 15 specialized adult CHD centers in Canada formed
the Canadian Adult Congenital Heart (CACH) Network. Attendance for at least 1
follow-up appointment at a CACH center before the age of 22 years was
ascertained for all eligible patients. Attendance at a CACH center provides a
clear criterion for successful transfer. RESULTS: In the total cohort, 47%
(95% confidence interval [CI]: 42-52) had transferred successfully to adult
care. There was no difference in rates of successful transfer between patients
consenting to complete questionnaires (48%) and those who declined (47%). More
than one quarter (27%) of the patients reported having had no cardiac
appointments since 18 years. In multivariate analyses of the entire cohort,
successful transfer was significantly associated with more pediatric
cardiovascular surgeries (odds ratio [OR]: 2.47; 95% CI: 1.40-4.37), older age
at last visit to the Hospital for Sick Children (OR: 1.29; 95% CI: 1.10-1.51),
and documented recommendations in the medical chart for follow-up at a CACH
center. In multivariate analyses of the patients completing questionnaires,
successful transfer was significantly related to documented recommendations
and patient beliefs that adult CHD care should be at a CACH center (OR: 3.64;
95% CI: 1.34-9.90). Comorbid conditions (OR: 3.13; 95% CI: 1.13-8.67), not
using substances (eg, binge drinking; OR: 0.18; 95% CI: 0.07-0.50), using
dental antibiotic prophylaxis (OR: 4.23; 95% CI: 1.48-12.06), and attending
cardiac appointments without parents or siblings (OR: 6.59; 95% CI:
1.61-27.00) also correlated with successful transfer. CONCLUSIONS: This is the
first study to document the percent of young adults with a chronic illness who
successfully transfer to adult care in a timely manner. Patients were from an
entire birth cohort from the largest pediatric cardiac center in Canada, and
outcome data were obtained on all eligible patients. Similar data should be
obtained for other chronic illnesses. There is need for considerable
improvement in the numbers of young adults with CHDs who successfully transfer
to adult care. At-risk adolescents with CHDs should begin the transition
process before their teens, should be educated in the importance of antibiotic
prophylaxis, should be contacted if a follow-up appointment is missed, and
should be directed to a specific CHD cardiologist or program, with the planned
timing being stated explicitly. Adult care needs to be discussed in the
pediatric setting, and patients must acquire appropriate beliefs about adult
care well before transfer. Developmentally appropriate, staged discussions
involving the patient, with and without parents, throughout adolescence may
help patients acquire these beliefs and an understanding of the need for
ongoing care. Improved continuity of pediatric care and provision of clear
details for adult follow-up might be sufficient to cause substantive
improvements in successful transfer. An understanding of why patients drop out
of pediatric care may be needed to improve the continuity of care throughout
adolescence. Almost one quarter of the patients believed adult care should be
somewhere other than at a CACH center despite opposite recommendations. For
these patients, a single discussion of adult care during the final pediatric
visit may be too little, too late. In addition to earlier discussions,
multiple mechanisms such as referral letters and transition clinics are needed.
Similarly, patients engaging in multiple risky or poor health behaviors such
as substance use may need more intensive programs to make substantial changes
in these behaviors, which hopefully would lead to successful transfer. Overall,
these data support the view that transition to adult care (a planned process
of discussing and preparing for transfer to an adult health center) is
important and should begin well before patients are transferred. The future
health of adults with chronic conditions may depend on our ability to make
these changes.
32.- Health status and health-related quality of life in a population-based sample of neonatal intensive care unit graduates. Pediatrics. 2004 Mar;113(3 Pt 1):594-600. Klassen AF et cols . Centre for Community Child Health Research, Department of Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada.
OBJECTIVE: To measure the health status (HS) and health-related quality of life (HRQL) of preschoolers who were admitted to a neonatal intensive care unit (NICU) at birth and their family caregivers and to investigate differences in HS and HRQL in relation to gestational age and major morbidity experienced during the NICU stay. METHODS: Retrospective cross-sectional survey was conducted in the province of British Columbia, Canada. A total of 1140 of 2221 children who were admitted at birth to the 3 tertiary care NICUs in the province and 393 of 718 healthy full-term children recruited from 2 of these hospitals were studied. The main outcome measures were Infant and Toddler Quality of Life Questionnaire (ITQOL), Health Status Classification System Preschool Version (HSCS-PS), and Child Behavior Checklist/1.5-5 (CBCL) RESULTS: The overall response rate was 55%; the response rate for families that we located was 67.1%. NICU children differed from healthy children on the ITQOL in physical abilities, growth and development, temperament/moods, behavior, and general health perceptions, and caregivers differed on both parent-impact scales. On the HSCS-PS, proportionally more NICU children had a health problem in the following areas: sight, speech, getting around, using hands and fingers, taking care of self, learning and remembering, thinking and solving problems, pain and discomfort, general health, and behavior. The NICU sample reported more behavioral problems on the CBCL/1.5-5. Poorer HS and HRQL were reported for infants who were born at <27 weeks' gestation and for children who experienced > or =1 major morbidities during their NICU stay. CONCLUSIONS: Preschool-aged children with conditions that require NICU care and their family caregivers had poorer HS and HRQL in a range of domains compared with healthy children. There were also differences within the sample by gestational age and major morbidity. The differences in health were small using the ITQOL and CBCL/1.5-5 but larger using the HSCS-PS.
33.- Incidence of outpatient visits and hospitalizations related to influenza in infants and young children. Pediatrics. 2004 Mar;113(3 Pt 1):585-93. O'Brien MA, Uyeki TM, Center for Child Health Care Studies, Harvard Medical School and Harvard Pilgrim Health Care, Boston, Massachusetts 02215, USA.
OBJECTIVE: The Advisory
Committee on Immunization Practices currently encourages influenza vaccination
for all children aged 6 to 23 months when feasible, based on studies that have
demonstrated that young children have high hospitalization rates attributable
to influenza. The Advisory Committee on Immunization Practices recently voted
to recommend influenza vaccination for all children beginning during the
2004-2005 influenza season; information on the rate of outpatient visits due
to influenza is needed to better evaluate the potential health impact and cost-effectiveness
of the recommendation. We estimated the incidence of outpatient visits as well
as hospitalizations for specific acute respiratory illnesses and for
influenza-associated outpatient-visit and hospitalization rates among healthy
infants and children in a Massachusetts health maintenance organization.
DESIGN/METHODS: Surveillance data were used to identify when influenza viruses,
respiratory syncytial viruses, and parainfluenza viruses were circulating in
the greater Boston area during 1994-2000. Using computerized medical records,
we identified outpatient visits and hospitalizations for selected respiratory
illnesses. Outpatient-visit rates and hospitalizations attributed to influenza
were calculated by subtracting the rate of visits during the periseasonal
period from the rate of visits during the influenza period. Rates were
stratified by age and risk for complications from influenza. RESULTS: Between
1994 and 2000, there were 188 139 outpatient visits and 885 hospitalizations
for respiratory illnesses in the study population. Among healthy children aged
6 to 23 months, the rate per 100 person-months for outpatient visits during
influenza periods was 14.5 (95% confidence interval [CI]: 13.9 to 15.1), and
the excess rate that could be attributed to influenza compared with the
periseasonal period was 1.8 (95% CI: 1.1 to 2.4). Among healthy children, the
rate of hospitalizations for acute respiratory disease was 10.4 per 10 000
person-months (95% CI: 6.0 to 17.0), and the rate that could be attributed to
influenza when compared with the periseasonal baseline period was 3.9 (95% CI:
-2.0 to 0.0). Among children who were at high risk for complications from
influenza, the rate of outpatient visits per 100 person-months was 28.7 (95%
CI: 26.6 to 30.9) during influenza periods. The rate of hospitalizations among
high-risk children was 44.6 per 10 000 person-months (95% CI: 19.0 to 17.0).
CONCLUSION: Influenza season is associated with a substantial increase in
outpatient visits by healthy children. These estimates of outpatient visits
for influenza will help quantify the potential health benefits and cost
savings from influenza vaccination of healthy children aged 6 to 23 months.
34.- A randomized trial of early versus standard inhaled nitric oxide therapy in term and near-term newborn infants with hypoxic respiratory failure. Pediatrics. 2004 Mar;113(3 Pt 1):559-64. Konduri GG, Solimano A, Sokol GM, MD for the Neonatal Inhaled Nitric Oxide Study Group. Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin 53226, USA.
OBJECTIVE: Inhaled
nitric oxide (iNO) reduces the use of extracorporeal membrane oxygenation (ECMO)/incidence
of death in term and near-term neonates with severe hypoxic respiratory
failure. We conducted a randomized, double masked, multicenter trial to
determine whether administration of iNO earlier in respiratory failure results
in additional reduction in the incidence of these outcomes. METHODS: Neonates
who were born at > or =34 weeks' gestation were enrolled when they required
assisted ventilation and had an oxygenation index (OI) > or =15 and <25 on any
2 measurements in a 12-hour interval. Infants were randomized to early iNO or
to simulated initiation of iNO (control). Infants who had an increase in OI to
25 or more were given iNO as standard therapy. RESULTS: The trial enrollment
was halted after 75% of target sample size was reached because of decreasing
availability of eligible patients. The 150 infants who were given early iNO
and 149 control infants had similar baseline characteristics. Arterial oxygen
tension increased by >20 mm Hg in 73% of early iNO and 37% of control infants
after study gas initiation. Control infants received standard iNO and
deteriorated to OI >40 more often than infants who were given early iNO. The
incidence of death (early iNO, 6.7% vs control, 9.4%), ECMO (10.7% vs 12.1%),
and their combined incidence (16.7% vs 19.5%) were similar in both groups.
CONCLUSION: iNO improves oxygenation but does not reduce the incidence of ECMO/mortality
when initiated at an OI of 15 to 25 compared with initiation at >25 in term
and near-term neonates with respiratory failure.
35.-Both relative insulin resistance and defective islet beta-cell processing of proinsulin are responsible for transient hyperglycemia in extremely preterm infants. Pediatrics. 2004 Mar;113(3 Pt 1):537-41. Mitanchez-Mokhtari D, Lahlou Service de Reanimation Pediatrique et Neonatale, Hopital Necker-Enfants Malades, Paris, France.
OBJECTIVE: Many extremely preterm infants develop hyperglycemia in the first week of life during continuous glucose infusion. The objective of this study was to determine whether defective insulin secretion or resistance to insulin was the primary factor involved in transient hyperglycemia of extremely preterm infants. METHODS: A prospective comparative study was conducted in appropriate-for-gestational-age preterm infants <30 weeks of gestational age with the aim specifically to evaluate the serum levels of proinsulin, insulin, and C-peptide secreted during transient hyperglycemia by specific immunoassays. Three groups of infants were investigated hyperglycemic (n = 15) and normoglycemic preterm neonates (n = 12) and normal, term neonates (n = 21). In addition, the changes in beta-cell peptide levels were analyzed during and after intravenous insulin infusion in the hyperglycemic group. Data were analyzed using analysis of variance and analysis of variance for repeated measures. RESULTS: At inclusion, insulin and C-peptide levels did not differ in hyperglycemic subjects and in preterm controls. Proinsulin concentration was significantly higher in the hyperglycemic group (36.5 +/- 3.9 vs 23.2 +/- 0.9 pmol/L). Compared with term neonates, proinsulin and C-peptide levels were higher in normoglycemic preterm infants (23.2 +/- 0.9 vs 18.9 +/- 2.71 pmol/L and 1.67 +/- 0.3 vs 0.62 +/- 0.12 nmol/L, respectively). During and after insulin infusion in hyperglycemic neonates, plasma glucose concentration fell and proinsulin and C-peptide levels were lowered (18.4 +/- 7.6 and 20.7 +/- 4.5 pmol/L, respectively). CONCLUSION: These data suggest that 1) preterm neonates are sensitive to changes in plasma glucose concentration, but proinsulin processing to insulin is partially defective in hyperglycemic preterm neonates; 2) hyperglycemic neonates are relatively resistant to insulin because higher insulin levels are needed to achieve euglycemia in this group compared with normoglycemic neonates. These results also show that insulin infusion is beneficial in extremely preterm infants with transient hyperglycemia.
36.- Evaluation of neonatal intensive care for extremely low birth weight infants in Victoria over two decades: II. Efficiency. Pediatrics. 2004 Mar;113(3 Pt 1):510-4. Doyle LW; Victorian Infant Collaborative Study Group. Department of Obstetrics and Gynaecology, Royal Women's Hospital, 132 Grattan St, Carlton, Victoria 3053, Australia.
CONTEXT: Although the
increasing effectiveness of neonatal programs for extremely low birth weight (ELBW,
birth weight <1000 g) infants has been established from cohort studies, there
is a paucity of data on the relationship between the costs and the
consequences of neonatal intensive care. OBJECTIVE: To determine the changes
in the efficiency of neonatal intensive care for ELBW infants in Victoria,
Australia over 2 decades. DESIGN: Economic evaluation (cost-effectiveness and
cost-utility analyses) in a population-based cohort study of consecutive ELBW
infants born during 4 distinct eras (1979-1980, 1985-1987, 1991-1992, and
1997) followed to at least 2 years of age. SETTING: The state of Victoria.
PATIENTS: All ELBW live births of birth weight 500 to 999 g in the state in
the calendar years indicated (1979-1980: n = 351; 1985-1987: n = 560;
1991-1992: n = 429; 1997: n = 233). MAIN OUTCOME MEASURES: Costs were assessed
primarily by the consumption of hospital resources. The consequences included
survival and quality-adjusted survival rates at 2 years of age. RESULTS: The
cost-effectiveness ratios (expressed in Australian dollars for 1997) were
similar between successive eras at 5270 dollars, 3130 dollars, and 4050
dollars per life-year gained, respectively. The cost-utility ratios were
similar between successive eras at 5270 dollars, 3690 dollars, and 5850
dollars per quality-adjusted life-year gained, respectively, and were similar
to the cost-effectiveness ratios. The cost-effectiveness and cost-utility
ratios were generally higher in lower birth-weight subgroups, but there were
consistent gains in efficiency over time in infants of lower birth weight.
CONCLUSIONS: As there have been large increases in effectiveness from the late
1970s to the late 1990s, the efficiency of neonatal intensive care for ELBW
infants in Victoria has remained relatively stable.
37.- Evaluation of neonatal intensive care for extremely low birth weight infants in Victoria over two decades: I. Effectiveness. Pediatrics. 2004 Mar;113(3 Pt 1):505-9. Doyle LW; Victorian Infant Collaborative Study Group. Department of Obstetrics and Gynaecology, Royal Women's Hospital, 132 Grattan St, Carlton, Victoria 3053, Australia. lwd@unimelb.edu.au
CONTEXT: Although
individual components of neonatal intensive care have proven efficacy, doubts
remain about its overall effectiveness. OBJECTIVE: To determine the changes in
effectiveness of neonatal intensive care for extremely low birth weight (ELBW)
infants over 2 decades. DESIGN: Population-based cohort study of consecutive
ELBW infants born during 4 distinct eras: 1979-1980, 1985-1987, 1991-1992, and
1997, all followed to at least 2 years of age. SETTING: The state of Victoria,
Australia. PATIENTS: All ELBW live births of birth weight 500 to 999 g in the
state in the calendar years indicated (1979-1980 [n = 351]; 1985-1987 [n =
560]; 1991-1992 [n = 429]; 1997 [n = 233]). Survivors were assessed at 2 years
of age by pediatricians and psychologists blinded to perinatal details. The
follow-up rates were high for each ELBW cohort (1979-1980: 100% [89 of 89];
1985-1987: 100% [212 of 212]; 1991-1992: 98% [237 of 241]; 1997: 99% [168 of
170]). MAIN OUTCOME MEASURES: Survival and quality-adjusted survival rates at
2 years of age. RESULTS: The survival rate to 2 years of age improved
significantly between successive eras (absolute increase and 95% confidence
interval: 1985-1987 vs 1979-1980, 12.5% and 6.3%-18.4%; 1991-1992 vs
1985-1987, 18.3% and 12.1%-24.4%; 1997 vs 1991-1992, 16.8% and 9.2%-23.9%), as
did the quality-adjusted survival rate (absolute increase: 1985-1987 vs
1979-1980, 12.4%; 1991-1992 vs 1985-1987, 13.8%; 1997 vs 1991-1992, 13.2%).
Overall, the survival rate increased from approximately 1 in 4 (25%) in
1979-1980 to 3 in 4 (73%) in 1997, and the quality-adjusted survival rate also
increased threefold, from 19% in 1979-1980 to 59% in 1997. The biggest gains
in survival and quality-adjusted survival in the most recent era were in
infants in lighter birth-weight subgroups. CONCLUSION: The effectiveness of
neonatal intensive care for ELBW infants in Victoria improved progressively
from the late 1970s to the late 1990s.
38.- Normative neurobehavioral performance of healthy infants on the Neonatal Intensive Care Unit Network Neurobehavioral Scale. Pediatrics. 2004 Mar;113(3 Pt 2):676-8. Tronick EZ, Olson K, Child Development Unit, Children's Hospital, Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA.
Descriptive statistics for the Neonatal Intensive Care Unit Network Neurobehavioral Scale summary scores are provided for a sample of 125 full-term, healthy 1- to 2-day-old infants. The study sample is described, including demographic characteristics and infant and maternal medical characteristics. Descriptive statistics and percentiles are provided for the Neonatal Intensive Care Unit Network Neurobehavioral Scale summary scores. These tables can be used as quasinorms for comparison with other infants of this age.