Early neurodevelopmental outcome of very low birthweight infants

ABSTRACT. In the 18 months, January 1979 to July 1980, 149 infants who weighed ≤1500g at birth were cared for in the neonatal intensive care unit at Queen Victoria Medical Centre, Melbourne. During this period the neonatal survival rate for infants weighing 501–1000g was 57% and for those weighing 1001–1500g was 91%. Of the 123 neonatal survivors, four died within the first year after birth. One hundred and seventeen (98%) of 119 surviving infants have been assessed at follow-up. At a mean age of 12.3 months (corrected for prematurity), 11 (9%) survivors had physical handicaps only and four (3%) had developmental delay, including one child who was also physically handicapped. Nine of the 14 children with a defined handicap were considered to have significant functional handicap. Therefore 108 (92%) survivors are able to function within the normal range. These results suggest that the chance of survival for infants of very low birthweight has continued to increase whereas their handicap-rate has remained stable and relatively low.     

Survival of very low birthweight and very preterm infants in a geographically defined population

Objective : To determine in a geographically defined population 1 year survival of infants with a birthweight of less than 1500g or gestational age less than 32 weeks, and to establish the effect of postnatal age on predicted survival. Design : Cohort analysis of 72427 births to Welsh residents in 1993-94. Deaths were identified using the All Wales Perinatal Survey, a population-based surveillance of mortality between 20 weeks of gestation and 1 year of age. Main outcome measures : Birthweight- and gestation-specific infant mortality, and the effect of postnatal age, gender, and multiple pregnancy on predicted survival. Results : In normally formed infants 1 year survival at 24–25 weeks gestation was 35%, compared to 75% at 27–28 weeks, and 95% at 30–31 weeks. In infants with a birthweight of 500-699g 1 year survival was 18% compared to 70% at 800-999g, and 97% at 1300-1499g. The chances of survival improved markedly with increasing postnatal age; at 24–25 weeks gestation it was 35% at birth, 50% at 12 h, 66% at 7 days and 78% at 4 weeks. Infant mortality was higher in males, but multiple pregnancy had no effect. Conclusions : Up-to-date birthweight- and gestation-specific survival rates are essential for predicting the outcome of a newborn infant. The rapid change in the chances of survival with increasing postnatal age emphasises especially the importance of revising the prediction as the infant gets older, particularly during the first few days of life,     

The outcome of very low birth weight infants: past,present and future

This article is an attempt to review the impact of neotnatal intensive care on mortality and child-hood morbidity of VLBW infants. The evidence suggests that in the last decade there has been a significant reduction in neonatal mortality, particularly of the very tiny infants. However, although the data on morbidity is more difficult to interpret, there does not seem to have been a parallel decline in the rate of neurological impairment in infants. The implication of this for the future is discussed.     

Perinatal factors affecting survival of very low birthweight infants — a study from two hospitals

ABSTRACT. Three hundred and seventy-seven consecutive liveborn infants with a birthweight between 500g and 1500g born at two perinatal centres in the calendar years 1977 and 1978 and 40 outborn infants in the same weight group admitted to one of the hospitals during the same period were studied. Although the survival rates in individual 100g weight groups vary between 14.3% and 97.4%, overall survival rates for inborn and outborn infants in both hospitals were similar, ranging from 69.0% to 71.5%. Twenty-two perinatal factors were found to have a significant effect on survival, of which 15 were common to the inborn populations in both hospitals. Eight of these 22 factors were indicators of intrapartum asphyxia. Multiple regression analysis showed that whereas birthweight was the most important variable influencing outcome in one hospital, the infant's condition at birth is the most important in the other. This difference may be related to the aggressive approach to perinatal intensive care of extremely preterm infants in the latter hospital.     

Rehospitalization of very preterm infants

Rehospitalization rates of very preterm infants because of reasons that are related to neonatal morbidity states can be decreased with further improvement of neonatal intensive care provided.

Conclusion: Analysis of rehospitalization data should be included in follow-up programmes as a contribution to the development of strategies to improve neonatal care and the ultimate outcome for very-low-birthweight infants.     

Interventions to improve the oral feeding performance of preterm infants

Aim: Preterm infants have difficulty oral feeding. We hypothesized that a specific sucking and swallowing exercises vs. no intervention accelerate the attainment of independent oral feeding through a faster maturation of infants’ oral feeding skills (OFS). Methods: Very low birthweight infants were randomized to a control, sucking and swallowing groups. Sucking consisted of active sucking on a pacifier, and swallowing of placing a milk bolus (0.05–0.2 mL) on the tongue where the bolus rests prior to entering the pharynx. Primary outcome was days from start to independent oral feeding (SOF‐IOF). Secondary outcomes included overall transfer (OT, % volume taken/volume prescribed), proficiency (PRO, % volume taken at 5 min/volume prescribed), rate of transfer (RT, mL/min) over the entire feeding and infants’ OFS levels. OFS levels were defined by PRO and RT. Results: Days from SOF to IOF vs controls (21 ± 2) were similar for the sucking group (19 ± 2) and shorter for the swallowing group (15 ± 2; p = 0.019). Only the latter infants demonstrated more mature OFS levels than controls. Conclusion: The swallowing exercise is an efficacious intervention in facilitating the attainment of independent oral feeding, but not the sucking exercise. We speculate that the swallowing benefit resulted from an accelerated maturation of infants’ OFS levels.     

Shorter hospital stay for moderately preterm infants

AIM: To determine length of hospital stay (LOS) for moderately preterm infants during the last 20 years, and to identify factors affecting the number of bed-days. METHODS: Review of LOS for all infants delivered between 30 to 34 gestational weeks during 1983, 1988, 1993, 1998 and 2002. Exclusion criteria: life-threatening abnormalities, chromosomal anomalies and death during hospitalization. RESULTS: 564 included infants accounted for 20% of admissions and 48% of bed-days in the neonatal unit. Between 1983 and 2002, maternal age and use of nasal continuous positive airway pressure increased, use of antibiotics and mechanical ventilation decreased, whereas distributions for gestational age, birthweight, gender, smallness for gestational age, low Apgar score or incidence of respiratory distress syndrome did not change. For healthy inborn singletons discharged home, LOS decreased from 1983 (28+/-11 d, mean+/-SD values) to 2002 (14+/-7 d, p<0.05). Infants born more immature had longer LOS, but postconceptional age at discharge did not differ between age groups. CONCLUSION: LOS for moderately preterm infants has decreased as a result of individualized neonatal care and organization of homecare support. Shorter LOS is of benefit to the family, prevents overcrowding in the NICU and has important economic implications.     

The changing relationship between bronchopulmonary dysplasia and cognition in very preterm infants

Aim

To characterise the relationship between bronchopulmonary dysplasia (BPD) severity and cognition in the post‐surfactant era.

Methods

This was a single‐centre retrospective analysis of a cohort of infants born 2009–2012. Inclusion criteria were as follows: admission within 48 hours of birth, gestational age 22‐0/7–31‐6/7 weeks, birthweight 400–1500 g and Bayley Scales of Infant and Toddler Development‐III testing at 18–26 months corrected age. Infants (n = 151) were classified by BPD severity with the NIH Workshop definition. Generalised linear modelling and multivariate logistic regression were performed.

Results

Bayley cognitive score was not associated with BPD severity in univariate (p = 0.053) or multivariate (p = 0.503) analysis. About 27% of infants with no/mild BPD, 33% of infants with moderate BPD and 40% of infants with severe BPD had a cognitive score <85. There was no difference in the odds of cognitive score <85 based on BPD severity in univariate (p = 0.485) or multivariate analysis (p = 0.225). All infants with cognitive score <70 had severe BPD, although the association between cognitive score <70 and BPD severity was not significant.

Conclusion

We found no independent effect of BPD severity level on cognition. The likelihood of a cognitive score <85 was not associated with BPD severity.     

Spectrum of respiratory distress in very low birthweight neonates

The incidence, etiology and the outcome of respiratory distress in 243 consecutive livebom very low birth weight neonates (VLBW) were analysed. One hundred and forty six (60%) VLBW neonates developed respiratory distress. Hyaline membrane disease, congenital pneumonia and transient tachypnea of the newborn were the major underlying causes (35.6%, 28.1%, and 27.4% respectively). The mortality rate was significantly higher in neonates with respiratory distress (72 of 146,49.3%) than in those without distress (28 of 97,28.8%) (p <0.05). This differerce was more sharply reflected in the 1000-1249 birth weight group and in the 29–32 weeks gestation group. Respiratory distress is a significant determinant of VLBW mortality.     

Prenatal and postnatal factors affecting short-term survival of very low birth weight infants

Factors affecting the survival of 175 preterm infants born with body weight <1500 g were examined. The still-birth and perinatal mortality rates were 143 and 446 per 1000 births respectively; neonatal death rate was 447 per 1000 live births. Survival improved progressively with increasing gestational age, and survival was better for infants born after 27 weeks of gestation. Neither maternal nor labour and delivery variables significantly affected survival. Male infants had half the survival rate of females. Birth asphyxia, hypercapnia and respiratory distress syndrome were the most common forms of morbidity, occurring in >20% of the population. Infants with such pathology had significantly lower survival rates.Abbreviations VLBW very low birth weight - NICU neonatal intensive care units - PROM premature rupture of the membranes - RDS respiratory distress syndrome - RR relative risk - SGA small for gestational age - AGA adequate for gestational age - ELBW extremely low birth weight The Italian Collaborative Study on Preterm Delivery was carried out by the following investigators: Maurizio Bonati, Carlo Brambilla, Fabio Colombo and Gianni Tognoni, Milan (Co-ordinating Centre); Cristina Begher, Salvatore Bottino, Umberto Faluto and Mario Maccabruni, Monza (MI); Bruno Granati and Paola Zanor, Padova, Pierangelo Burtuletti, Gabriella Manenti and Giuliana Pasinetti, Bergamo; Carlo Corchia, Sassari; Enrico Bertino, Aldo Capra, Wanda Combetto, Maria Pia Corradin, Claudio Fabris and Claudio Martano, Torino; Michele Angiolillo and Luigi Gaioni, Mantova; Rosanna Casellato and Giorgio Suppi, Treviso; Augusto Montaguti, Cesena; Susanna Martignoni and Antonio Tomassini, Varese; Paolo Bianchi and Giuliano Palmerio, Seriate (BG); Fulvia Cellani, Francesco Grossi and Vincenzo Rossi, Lodi (MI); Antonia Carlino, Crena (CR); Alessandra Favero, Stefano Quaranta and Raffaella Tornaghi, Milan; Giuseppe Assenza, Fiesole (FI); Massimo Bardi, Arturo Manzoni, Daria Mattioni and Ferruccio Pizzigoni, Trescore (BG); Mario Berzioli and Vittorio Marsoni, Montebelluna (TV); Giovanni Buzzi and Angela Tudisco, Casale Monferrato (AL); Gabriele Oppo, Arezzo; Domenico Fichera, Calcinate (BG); Giuseppe Marraro and Alberto Vecchione, Merate (CO)     

Fluconazole prophylaxis prevents invasive fungal infection in high-risk, very low birth weight infants

OBJECTIVES: To evaluate the benefit of fluconazole prophylaxis in preventing invasive fungal infection in very low birth weight (VLBW) infants with central vascular access. STUDY DESIGN: A 3-year baseline period (1998 to 2000) was compared with a subsequent 3-year period (2001 to 2003) during which a different protocol for preventing invasive fungal infection was used. All infants with a birth weight < 1500 g and with central vascular access were eligible for the study. Fluconazole (Diflucan R) was administered for 28 days at a dose of 6 mg/kg every third day during the first week and daily after the first week. RESULTS: There were no significant differences between the baseline and the fluconazole groups in demographic characteristics or risk factors for fungal infection. Fungal infection developed in 9 of the infants in the baseline group and in none of those in the fluconazole group (P=.003). A trend of decreasing mortality rate between the 2 groups (12.6% vs 8.1%; P=.32) was observed but was not statistically significant. No adverse effects of fluconazole therapy were documented. CONCLUSIONS: Fluconazole prophylaxis appeared to be beneficial in preventing invasive fungal infection in VLBW infants.     

Changes in care and short-term outcome for very preterm infants in Estonia

Aim: To identify recent changes in short‐term outcome and care for very preterm infants in Estonia. Methods: Comparison of two population‐based cohorts of very preterm infants born alive at 22–31 gestational weeks. In 2007–2008, data were recorded prospectively in a neonatal register. For the cohort born in 2002–2003, the same variables were extracted retrospectively from the hospital records. Infants were followed up to discharge or death. Results: The cohort of 2007−2008 contained a higher proportion of infants born by caesarean section and of infants who received antenatal corticosteroids, maternal antibiotics, or surfactant therapy than the earlier cohort. A higher proportion of infants was admitted for care in 2007–2008 (98% vs. 94%; p = 0.013). During the study period, survival until discharge increased (85% vs. 78%; p = 0.041), although the length of hospital stay was unchanged. The use of mechanical ventilation, inotropes, and postnatal antibiotics decreased. Neonatal morbidity remained unchanged, except for a decrease in severe periventricular/intraventricular hemorrhage. Conclusion: The outcome for very preterm infants in Estonia has improved since 2002. With proactive perinatal management and less invasive neonatal care, survival until discharge increased without concomitant increases in neonatal morbidity and the length of hospital stay.     

Early maternal anxiety predicts cognitive and behavioural outcomes of VLBW children at 24 months corrected age

Aim: The present study examined the effects of maternal anxiety during infant hospitalization in the Neonatal Intensive Care Unit (NICU) on the child’s cognitive and behavioural development at 24 months corrected age. Parental anxiety following the birth of a very low birthweight (VLBW, <1500 g) infant may impede their capacity to be sensitive to the infant’s cues and adversely affect infant developmental outcomes. Methods: A sample of 88 mothers and their VLBW infants were recruited in the NICU; 57 were followed at 24 months corrected age. During the infant’s hospitalization, mothers completed a self‐report measure of trait anxiety. When the infants were 24 months corrected age, mother–child interaction was videotaped during free play at home. These videotaped observations were coded using Emotional Availability Scales. Child cognitive and behavioural outcomes were evaluated using the Bayley Scales of Infant Development (II) and the Child Behavior Checklist for Ages 1.5–5. Results: Maternal anxiety in the NICU was found to be a significant and independent predictor of child cognitive development and internalizing behaviour problems, controlling for maternal education and neonatal morbidity. Conclusion: These results suggest that early intervention programmes targeting anxious mothers of VLBW infants are indicated, to promote optimal developmental outcomes.     

Hindmilk and weight gain in preterm very low-birthweight infants

BACKGROUND: Feeding of own mother's milk to preterm very low-birthweight infants often results in suboptimal weight gain in these infants for whom energy requirements are high but in whom volume tolerance is limited. Therefore the purpose of the present paper was to investigate the effect of selective hindmilk feeding on the growth of preterm very low-birthweight babies. METHODS: Preterm very low-birthweight babies admitted into the Special Care Baby Unit of the Jos University Teaching Hospital, Nigeria between April 2000 and July 2001 were randomized to hindmilk and composite breast milk feeding for 2 weeks. End-points were weight, occipitofrontal head circumference and length. RESULTS: For small-for-gestational-age babies, the infants fed on hindmilk gained weight at a mean rate of 12.92 +/- 10.95 g/kg per day as compared with a mean rate of 5.01 +/- 17.37 g/kg per day for their controls on composite milk (P < 0.0001). For appropriate-for-gestational-age babies, the mean rate of weight gain for the hindmilk group was 12.99 +/- 10.75 g/kg per day while that for their controls on composite milk was 8.29 +/- 20.56 g/kg per day (P < 0.01). There were no significant differences in the rates of increase in length and occipitofrontal head circumference between the groups. The lipid content of the hindmilk was 1.6-fold that of composite milk. CONCLUSION: Preterm very low-birthweight babies fed hindmilk had a higher rate of weight gain compared to those fed composite milk. It is recommended that the hindmilk fraction of expressed breast milk be predominantly used for the feeding of preterm very low-birthweight babies while in hospital to help shorten their duration of hospital stay.