Reduced mortality in small premature infants treated at birth with a single dose of synthetic surfactant

A randomized controlled trial of Exosurf Neonatal, a synthetic exogenous surfactant, was performed. Exosurf was given to premature infants weighing 700-1350 g, by instillation down the endotracheal tube during mechanical ventilation, within 1 h of birth. Control infants were treated with air. Dose administration was performed in secrecy by clinicians who maintained the blind for 2 years. A total of 109 infants received air and 109 received Exosurf; 19 infants with congenital pneumonia or major malformations were excluded from the primary efficacy analysis. By the age of 28 days there were 14 deaths in the air group and 4 deaths in the Exosurf group, a 69% reduction with Exosurf (P = 0.020). Survival without bronchopulmonary dysplasia at the age of 28 days was significantly improved by 15% (P = 0.050). By the age of 1 year post-term there were 19 deaths in the air group and 10 deaths in the Exosurf group, a 42% reduction with Exosurf (P = 0.104). There were no significant changes in the incidence of bronchopulmonary dysplasia, pulmonary air leaks, intraventricular haemorrhage, patent ductus arteriosus, necrotizing enterocolitis or infection. The reduction in mortality indicates important results in high risk premature infants treated soon after birth with a single dose of Exosurf.     

Massage therapy improves neurodevelopment outcome at two years corrected age for very low birth weight infants

Background

Long term effects of massage therapy in very preterm newborns infants are still to be described. Few studies evaluated neurodevelopment just at six months, and included late preterm infants.

Objective

To study the effect of massage therapy on neurodevelopment of very low birth weight infants at two years corrected age.

Study design

Newborns with birth weight between ≥ 750 and ≤ 1500 g and gestational age ≤ 32 weeks were randomly assigned to massage therapy by mothers plus skin-to-skin care (Intervention Group) or just skin-to-skin care (Control Group) during their hospital stay. Growth and neurodevelopment outcome were evaluated at 2 years corrected age.

Results

We followed 73 newborns (35 in Intervention Group, and 38 in Control Group). Both groups were similar in neonatal data. Growth at 2 years corrected age was similar in both groups. Intervention Group had borderline higher Psychomotor Development Index and significantly higher Mental Development Index scores than Control Group.

Conclusions

We suggest that massage therapy by mothers combined to skin-to-skin care during neonatal hospital stay improves neurodevelopment outcome at 2 years corrected age.     

Improved outcome in very low birth weight infants from 1977 to 1983

Changes of mortality and neurological morbidity in 351 very low birth-weight infants cared for in the neonatal intensive care unit of the Children's Hospital Tübingen during the years 1977 to 1983 are reported. The main finding was a survival rate increasing from 69.5% in 1977–79 to 76.6% in 1982–83 and a coinciding frequency of severe neurological sequelae decreasing from 9.2%–3.7%. The incidence of minor neurodevelopmental problems remained unchanged. However, mortality after discharge was found to be increased during the period observed. In conclusion, the intensification of neonatal intensive care in our hospital did not only reduce mortality but also the rate of severe neurological sequelae, thus not only survival rate but also the quality of survival could be improved.Abbreviations VLBW very low birth weight - LBW low birth weight - NICU neonatal intensive care unit - BPD bronchopulmonary dysplasia     

Cognitive performance at school age of very low birth weight infants with bronchopulmonary dysplasia

The hypothesis was that bronchopulmonary dysplasia (BPD) adversely affects cognitive performance at school age. This prospective cohort study examined three groups of children at 8 to 10 years of age. Group 1 (n = 311) consisted of very low birth weight (VLBW) infants without BPD and Group 2 (n = 95) consisted of VLBW infants with BPD. Group 3 (n = 188) consisted of term infants without BPD. Regression analysis determined the effect of BPD on eight performance measures while controlling for possible confounding variables. Children in Group 3 had the best performance and children in Group 2 had the poorest performance on all measures. These differences were significant (p = .0001) for the Full Scale IQ, Performance IQ, and reading and math grades and ages. Children in Groups 3 and 1 performed better than children in Group 2 for the Verbal IQ (p = .0001) and the Developmental Test of Visual-Motor Integration (p = .0012), but for these two measures there was no significant difference between children in Groups 3 and 1. Thus, poorer performance was found in VLBW infants with a history of BPD.     

Developmental outcome of very low birth weight infants in a developing country

Background  

Advances in neonatal care allow survival of extremely premature infants, who are at risk of handicap. Neurodevelopmental follow up of these infants is an essential part of ongoing evaluation of neonatal care. The neonatal care in resource limited developing countries is very different to that in first world settings. Follow up data from developing countries is essential; it is not appropriate to extrapolate data from units in developed countries. This study provides follow up data on a population of very low birth weight (VLBW) infants in Johannesburg, South Africa.     

Effect of a bovine surfactant in very low birth weight premature infants with congenital pneumonia

15 VLBW-infants, who were classified to suffer from congenital pneumonia, were treated with a bovine surfactant. Mean gestational age was 25.5 weeks (range 23-27 weeks), mean birth weight was 700 g (range 530-930 g). Surfactant was instilled intratracheally at a mean dose of 41 mg/kg body weight (b.w.) (range 30-50 mg) 8 h after birth (range 6-12 h), if the fraction of inspired oxygen (FiO2) was greater than 0.5 or the peak inspiratory pressure (PIP) was greater than 22 cm H2O (b.w. less than 750 g) or greater than 25 cm H2O (b.w. 751-1000 g). Retreatment up to a total maximum of 4 doses of surfactant was permitted. Surfactant treatment reduced FiO2 from a pretreatment value of 0.79 to 0.50 one hour after application, however, 12 h later FiO2 had increased again to 0.75. Ventilation pressures showed a slight decrease during 12 h after surfactant treatment. 6 infants received 1 dose, multiple doses were given to 9 infants. 5 infants survived, 4 infants died from respiratory failure, 4 from sepsis and 2 from severe intracranial haemorrhage.     

Hypothalamic-pituitary-adrenal axis function in very low birth weight infants treated with dexamethasone

The effect of dexamethasone therapy on hypothalamic-pituitary-adrenal axis function was prospectively investigated in very low birth weight infants with bronchopulmonary dysplasia. Ten infants (mean +/- SD birth weight 825 +/- 265 g, gestation 25.8 +/- 1.9 weeks, postnatal age 33.1 +/- 17.7 days) initially received intravenous dexamethasone, 0.5 mg/kg per day for 3 days, and then were weaned over a period of 45 +/- 19.0 days to a replacement dose, followed by a metyrapone test. Morning plasma cortisol and 11-deoxycortisol levels were measured before and after an oral metyrapone dose given at midnight. Five infants (group A: birth weight 876 +/- 313 g, gestation 26.2 +/- 1.3 weeks, age of entry 31.8 +/- 22.8 days) had normal metyrapone test results, and five infants (group B: 778 +/- 234 g, 25.4 +/- 2.5 weeks, 34.4 +/- 13.4 days) had suppressed test results. Group A infants, in comparison with group B infants, had higher basal cortisol plasma levels (14.52 +/- 12.53 and 3.00 +/- 1.38 micrograms/dL, P = .047), higher postmetyrapone 11-deoxycortisol plasma levels (3.11 +/- 3.93 and 0.55 +/- 0.51 micrograms/dL, P = .028), larger differences between basal and postmetyrapone cortisol levels (7.10 +/- 4.67 and 2.12 +/- 1.31 micrograms/dL, P = .047), and larger differences between basal and postmetyrapone 11-deoxycortisol levels (2.99 +/- 3.93 and 0.29 +/- 0.25 micrograms/dL, P = .009). The hypothalamic-pituitary-adrenal axis function in group B infants eventually returned to normal when they continued to receive low-dose dexamethasone therapy after a period of 36.8 +/- 16.6 days.(ABSTRACT TRUNCATED AT 250 WORDS)     

Physiology of infants with very low birth weight

Advances in neonatal management have resulted in dramatic increases in survival in infants with birth weights less than 1,500 g. Extensive basic science and clinical research has led to a more comprehensive understanding of the physiological differences between the VLBW infant and larger neonates. Meticulous attention must be paid to appropriate fluid, electrolyte, nutrition, and temperature maintenance to achieve homeostasis and growth. Additionally, the clinician must be aware of the diagnostic and treatment modalities for the common complications seen in the premature infant to minimize mortality and long-term morbidity.     

Improved vitamin A supplementation regimen for breastfed very low birth weight infants

OBJECTIVE: Preterm infants usually have low retinol status at birth and at discharge from hospital. We have evaluated a new protocol designed to improve plasma retinol in very low birth weight infants (VLBW, birth weight < 1500 g). DESIGN: An open intervention trial was conducted in which vitamin A was given in a human milk fortifier. The daily dose of vitamin A varied according to bodyweight and was given mixed with human milk instead of as a bolus. Blood samples were collected at inclusion and at discharge from hospital. Plasma was analyzed for retinol using high-performance liquid chromatography. The daily intake of vitamin A and plasma retinol concentration was compared with the vitamin protocol normally used in Norwegian hospitals. RESULTS: Sixty VLBW infants were included and 53 completed the study. At discharge from hospital, the reference group had lower median plasma retinol concentrations compared to the modified group (0.30 microM vs. 0.49 microM, p = 0.008). Fewer infants in the modified group had plasma retinol levels below 0.35 microM (indicating reduced hepatic stores) compared to infants in the reference group (44% vs. 69%, p = 0.04). CONCLUSION: The modified protocol improved plasma retinol levels at discharge compared to the reference protocol.     

Respiratory distress syndrome in very low birth weight infants with occasionally normal surfactant phospholipids

Lung effluent phospholipids were analysed in 120 very lwo birth weight (560–1500g) infants within 12 h from birth. The phospholipid profile accurately predicted the presence or absence of respiratory distress syndrome (RDS). However, in three of the 72 RDS cases, the phospholipids revealed no biochemical abnormality as compared to lung effluent from newborns without RDS. In RDS with normal phospholipids, only the lipid-rich fractions of the aspirate were surface active, whereas the protein-rich fraction of the aspirate inhibited the surface activity of lung effluent from normal newborns, suggesting the presence of a surfactant inhibitor. The pathogenesis and treatment of RDS with normal surfactant phospholipids may prove to be different from classical RDS.Supported by the Finnish Heart Foundation, the Paulo Foundation, and the Foundation for Pediatric Research (Finland)     

极低体重儿呼吸暂停的有关问题

早产儿呼吸暂停 (ａｐｎｅａｏｆｐｒｅｍａｔｕｒｉｔｙ ,ＡＯＰ)常发生于矛盾睡眠期 ,与呼吸中枢调节功能不成熟有关 ;呼吸暂停发生的频率及严重程度常与胎龄成反比。当呼吸暂停 >15～ 2 0ｓ ,或呼吸显著不规则时 ,可影响组织的氧合状态 ,尤其是在极低体重儿 ,呼吸暂停与发生     

Crying behaviour in early infancy is associated with developmental outcome at two years of age in very low birth weight infants

AIM: To evaluate the association between infant fussing and crying and developmental outcome in very low birth weight (VLBW) infants. METHODS: Hundred and seventeen VLBW infants were followed up to 24 months of corrected age. The duration of fussing and crying and frequency of fuss/cry bouts were measured at term 6 weeks and 5 months of corrected age. Cognitive and motor development was assessed at 24 months of corrected age. RESULTS: The increased duration of combined fuss/cry at term associated with lower psychomotor developmental index (PDI), [regression coefficient (b)=-0.83, p=0.025]. Crying at term associated negatively with mental developmental index (MDI) (b=-0.91, p=0.040) and PDI (b=-1.10, p=0.015). The associations between fuss/cry and PDI, and crying and PDI persisted in multiple regression analysis (b=-0.89, p=0.030 and b=-1.23, p=0.018, respectively). Excessive fuss/cry (>or=180 min/day) at term associated with lower PDI (p=0.005) and at 6 weeks with lower MDI (p=0.024) and PDI (p=0.012). Increase in the frequency of fuss/cry bouts at 5 months associated with higher PDI in both simple (b=2.90, p=0.045) and in multiple regression analysis (b=3.60, p=0.019). CONCLUSIONS: In VLBW infants, longer duration of fussing and crying in very early infancy, but not at 5 months, is associated with less optimal development at 24 months of age.     

Neurodevelopmental outcomes of very low birth weight and extremely low birth weight infants at 18 months of corrected age associated with prenatal risk factors

Background

Very premature infants occasionally have neurodevelopmental disabilities. However, there have been quite limited data on prenatal risk factors associated with their neurodevelopmental outcomes.

Aim

To clarify the relationship between prenatal risk factors and neurodevelopmental outcomes of very premature infants.

Study design

The study design is a retrospective review.

Subjects

One hundred seventy Japanese women with a singleton pregnancy and their infants whose birth weight being less than 1500 g were included. We classified those infants into 118 appropriate for gestational age (AGA) and 52 small for gestational age (SGA) infants.

Outcome measures

Infants' neurodevelopmental outcomes at 18 months of corrected age were evaluated by the Kyoto Scale of Psychological Development 2001 (KSPD). We analyzed and compared the infants' outcomes and prenatal risk factors between two groups.

Results

Mortality and rate of infants unevaluable by KSPD because of severe impairment were not significantly different between those groups. However, the developmental quotient score of the cognitive-adaptive area in SGA infants born between 25 and 31 weeks of gestation was significantly lower than that in AGA infants randomly selected as gestation-matched controls. More advanced gestational age and heavier birth weight protected against adverse neurodevelopmental outcomes in both groups. Moreover, male infants were related to the excess risk of adverse neurodevelopmental outcomes in the SGA group.

Conclusion

In view of the neurodevelopment of the infants, it seems that the most efficient obstetric strategy for improving prognosis of premature infants should be targeted to prolong the pregnancy period as long as the reassuring fetal status and maternal stable health condition are being confirmed.     

Growth of very low birth weight infants at 12 months corrected age in southern Brazil

The objective of this article is to describe growth of very low birth weight infants born in southern Brazil. All infants weighing < or =1500 g were followed up until 12 months corrected age (CA). Growth was recorded at 40 weeks, 6 and 12 months CA. Catch up was considered if the measures were > or =-2 SD of World Health Organization growth charts for weight and length; and of National Center for Health Statistics for head circumference. One hundred and ninety three infants born were followed up for the study. At 40 weeks CA, 57.8% patients achieved catch-up in weight and 50.9% in length. At 6 months CA, 82.2% achieved catch-up for weight and length and at 1 year CA, 92% achieved catch-up in weight and 86.9% in length. Catch-up in head circumference was achieved for 93.4%, 85.9% and 85% patients at 40 weeks, 6 months and 12 months CA, respectively. At 12 months CA, no catch-up in weight, length and head circumference was related to higher SNAPPE-II (P = 0.046) and periventricular leukomalacia (PVL) (P = 0.003); longer time to achieve full enteral nutrition at the neonatal intensive care unit (NICU) (P = 0.037), lower maternal education (P = 0.018) and PVL (P = 0,003); higher SNAPPE-II (P = 0,004), PVL (P = 0.005) and longer time to achieve full enteral nutrition at the NICU (P = 0.044), respectively. In conclusion, PVL and higher SNAPPE-II were important factors to catch-up delay. Catch-up growth was high at 12 months CA.     

Hyperbilirubinemia in low birth weight infants and outcome at 5 years of age.

The collaborative national survey on morbidity and mortality in preterm and small for gestational age infants in the Netherlands enrolled initially 1338 infants born in 1983. The relationship between maximal serum total bilirubin concentration in the neonatal period and neurodevelopmental outcome in the survivors of this cohort was studied. This relationship at the corrected age of 2 years was previously reported. A dose-response relationship between maximal serum total bilirubin concentration and risk of adverse outcome was observed in the 831 surviving children. The present study reassessed the relationship at the age of 5 years in 814 children. There was no significant difference in mean maximal serum total bilirubin concentration between the children with and without a handicap. This was confirmed by logistic regression analysis. After correction for seven suspected confounding factors (gestational age, birth weight, intracranial hemorrhage, ventriculomegaly, seizures, bronchopulmonary dysplasia, and socioeconomic status) the estimated odds ratio was 1.2 (confidence interval 0.89, 1.43) per 50 mumol/L increase of total bilirubin. However, in this analysis an interaction between bilirubin and intracranial hemorrhage was observed. Therefore, the cohort was divided into two groups according to the absence or presence of an intracranial hemorrhage. Logistic regression analysis including four suspected confounding factors (gestational age, ventriculomegaly, seizures, and socioeconomic status) was then again applied. In children who had suffered from an intracranial hemorrhage in the neonatal period the estimated odds ratio was 1.84 (confidence interval 1.08, 3.15) per 50 mumol/L increase of bilirubin. Similar results were obtained treating bilirubin as a categorized exposure. The odds ratio in children without a hemorrhage was 1.05 (confidence interval 0.80, 1.38), probably because of the small number of surviving handicapped children.     

Impact of very low birth weight infants on the family at 3 months corrected age

Background

Very low birth weight infants (VLBW, <1500 g) have increased impact on families compared to term infants. However, there is limited research examining this impact in the first months post-discharge.

Aim

To determine maternal, neonatal, and infant characteristics associated with greater impact on the family at 3 months corrected age in VLBW infants. It was hypothesized that social/environmental and medical risk factors would be associated with higher impact.

Study design

Maternal, neonatal, and infant data were collected prospectively. Parents completed the Impact on Family, Family Support, and Family Resource Scales. Associations between characteristics and impact scores were analyzed by t-test and Pearson's correlation. Regression models for each impact score identified significant risk factors for impact.

Subjects

152 VLBW infants born February 28, 2007 to September 5, 2008 who had a follow-up evaluation at 3 months corrected age.

Outcome measure

Impact on family.

Results

Siblings in the home, neonatal medical risk factors, longer hospitalization, more days on ventilator or oxygen, lower gestational age, lower social support, and poorer family resources were associated with increased impact. Multivariate analyses identified siblings in the home, poorer family resources, lower gestational age, and oxygen requirement at 3 months as the most important predictors of impact.

Conclusions

Social/environmental and medical risk factors contribute to impact on family. Families with identified risk factors should receive support services to assist them in coping with the burden of caring for a VLBW infant.     

Early amplitude integrated electroencephalography and outcome of very low birth weight infants

Objective: Amplitude integrated electroencephalography (aEEG) has been used in neonates in various clinical and research applications. We hypothesized that an abnormal aEEG score could be used as a predictor of short‐term adverse outcome. Methods: Very low birth weight infants were enrolled in a prospective observational cohort study. Two channel 12‐hour continuous aEEG recordings were performed within 48 h of life and at 1 week of age. Recordings were classified as abnormal if they correspond to a 2 point difference in score. Short‐term adverse outcome was defined as either death or Bayley scales ≤70 at 4 months corrected age. Results: One hundred infants were enrolled. Their average gestational age was 27.9 ± 2.6 weeks and average birth weight was 997 ± 299 gram. Fifteen enrolled infants died, one was withdrawn, 29 lost to follow up, and 55 examined at 4 months. Those with adverse outcome had significantly increased percentages of abnormal EEG at 1 week of life (31% vs. 8%), severe intraventricular hemorrhage (IVH) (27% vs. 4.5%), intubation in the delivery room (45% vs. 16%), and increased average days of mechanical ventilation (16 days vs. 4 days). Combining abnormal aEEG at 1 week of life to severe IVH on early head ultrasound increased the sensitivity of ultrasound to detect short‐term adverse outcome from 27% to 50%. Conclusion: aEEG is feasible in premature infants and when its data at 1 week of life are combined with early head ultrasound, sensitivity for detecting short‐term adverse outcomes was increased.