Motor and cognitive outcome at school age of children with surgically treated intestinal obstructions in the neonatal period

Background

The motor and cognitive outcome at school age of newborn children with surgically treated intestinal obstructions is unknown. Physiological stress and anesthesia may potentially be harmful in the period of early brain development in newborn infants.

Objective

To determine motor and cognitive outcome at school age in children with surgically treated intestinal obstructions as newborns, and to identify clinical risk factors for adverse outcome.

Study design

Cohort study of infants born between 1995 and 2002 with atresia, stenosis, or intestinal malrotation. At 6 to 13 years we assessed their motor functions, intelligence, attention, visual perception, visuomotor integration, and verbal memory.

Results

Of 44 children three (7%) died. Twenty-seven survivors (66%) were included for follow-up (median gestational age 36.7 weeks, birth weight 3000 g). Motor outcome was abnormal (< 5th percentile) in 22% of the children, which was significantly more than in the norm population (P < 0.01). Scores on selective attention were abnormal in 15% of the children (P < 0.01). Other cognitive functions were not affected. Lower birth weight and intestinal perforation were risk factors for poorer motor outcome (R² = 53.0%), intrauterine growth restriction was a risk factor for poorer selective attention (R² = 36.6%).

Conclusions

Children treated surgically for intestinal obstructions in the neonatal period had an increased risk for poor motor functioning and selective attention at school age. Low birth weight, intrauterine growth restriction and intestinal perforation were risk factors for adverse outcome. We recommend to closely follow the motor and attentional development of these children.     

Family functioning, burden and parenting stress 2 years after very preterm birth

Background

Examining rates of difficulties in family functioning following very preterm birth has been a relatively neglected area of research.

Aims

To examine family functioning, burden and parenting stress in families with very preterm compared with term born children, and investigate influences of parental mental health problems and child neurodevelopmental disability on family outcomes in families with preterm children.

Study design

Participants were 184 very preterm and 71 term children and their parents. Parents completed the Family Assessment Device, Parenting Stress Index and Impact on Family questionnaires when their children were 2 years old (corrected for prematurity). Parental mental health and social risk information were also collected. Children were assessed for neurodevelopmental disability.

Results

Families with very preterm children reported poorer family functioning (p = .03) compared with families with term born children, with less evidence for differences between families with very preterm and term born children in parenting stress and family burden. Within very preterm families, parental mental health problems were associated with higher levels of parenting stress (p = .001), and parents of children with a neurodevelopmental disability were more likely to report higher family burden (p = .04).

Conclusions

For families with very preterm children, parental mental health symptoms and child neurodevelopmental disability may identify families at risk of greater stress and burden who may benefit from additional support.     

Cardiovascular and metabolic outcome in 6-8 year old offspring of women with type 1 diabetes with near-optimal glycaemic control during pregnancy

Background

High maternal glucose concentrations during diabetic pregnancy may lead to health problems in the offspring later in life. We showed in a previous nationwide study on pregnancy outcome in type 1 diabetic women that prepregnancy care was good and a near-optimal glycaemic control during pregnancy was achieved (mean HbA1c 6.2%).

Aims

We investigated to what extent current care and treatment of pregnant women with type 1 diabetes were related to cardiovascular and metabolic disturbances in the offspring at school age. Additionally, we studied the influence of level of maternal glycaemic control, preterm birth and neonatal macrosomia (birth weight > p90).

Study design

Observational cohort study.

Subjects

6-8 year old offspring of women with type 1 diabetes (ODM, n = 213) and a control group of children of non-diabetic women (n = 79).

Outcome measures

BMI, blood pressure, parameters of fasting glucose regulation and lipid metabolism, components of the metabolic syndrome (overweight, hypertension, impaired fasting glucose, dyslipidaemia).

Results

Parameters of fasting glucose regulation and lipid metabolism and the frequency of components of the metabolic syndrome did not significantly differ between ODM and controls. Systolic blood pressure was slightly higher in ODM. The influence of level of maternal glycaemic control, preterm birth and neonatal macrosomia on outcome in ODM was limited.

Conclusions

Current care and treatment of pregnant women with type 1 diabetes result in cardiovascular and metabolic outcome in the offspring at 6-8 years of age that is comparable to that in children of non-diabetic women. Further follow-up should substantiate these results at later age.     

Impact of histological chorioamnionitis, funisitis and clinical chorioamnionitis on neurodevelopmental outcome of preterm infants

Background

The role of chorioamnionitis in neurodevelopment of preterm infants is not fully understood.

Aim

To examine the association between different indicators of intrauterine inflammation (clinical chorioamnionitis, histological chorioamnionitis and funisitis) and neurodevelopmental impairment in very preterm infants.

Methods

Preterm infants with a birth weight of < 1500 g or a gestational age of < 32 weeks were included. Follow-up evaluation up to 2 years of age consisted of neurological examination, neurodevelopmental assessment and visual and audiologic tests. Outcome data were compared between the chorioamnionitis and the control groups, controlling for gestational age, birth weight and Apgar score at 5 min.

Results

One hundred seventy-seven patients comprised the study population (mean gestational age 29 ± 2 weeks, mean birth weight 1167 ± 344 g). Histological chorioamnionitis was present in 49% of placentas, whereas funisitis was observed in 25%. In 57% cases clinical maternal chorioamnionitis was suspected. Follow-up was available for 130 (82%) patients. Infants with funisitis, compared with controls, had a significantly higher incidence of moderate to severe disability (18% vs 5%, OR 4.07; 95% CI 1.10-15.09).

Conclusion

The results of this study suggest that, unlike a broad definition of histological chorioamnionitis including inflammation of maternal or fetal placental tissues, funisitis may entail a higher risk of moderate to severe disability at 2 years of age in preterm infants.     

Uniform treatment thresholds for hyperbilirubinemia in preterm infants: background and synopsis of a national guideline

Background

To prevent severe hyperbilirubinemia and bilirubin neurotoxicity, the American Academy of Pediatrics' management guideline for hyperbilirubinemia in near term infants is used worldwide. A leading guideline for jaundiced preterm infants is lacking whereas the risk on severe hyperbilirubinemia is high in these infants. Our aim was to define uniform treatment thresholds for jaundiced preterm infants. In this article we present the history and a synopsis of this novel national guideline.

Study Design

A survey on guidelines for hyperbilirubinemia in preterm infants was sent to all Dutch Neonatal Intensive Care Units (NICUs). After comparison with international guidelines, a new consensus-based guideline was developed.

Results

Treatment thresholds of all 10 NICUs were based on Total Serum Bilirubin (TSB) and related to birth weight (n = 9) and gestational age (n = 1). NICUs used age-specific (n = 6) or fixed (n = 4) TSB-thresholds resulting in a large range of thresholds (maximal 170 μmol/L for phototherapy and 125 μmol/L for exchange transfusion). Acidosis, asphyxia, sepsis, active hemolysis and intraventricular hemorrhage were the most frequently used risk factors. Consensus was agreed upon TSB-based treatment thresholds, categorized in 5 birth weight groups and divided in high and low risk infants.

Conclusion

There was no standardized care for jaundiced preterm infants in the Netherlands. In addition to the internationally used guideline for (near) term infants, a novel “consensus based” guideline for preterm infants with a gestational age of less than 35 weeks has been developed and implemented in the Netherlands. This guideline is approved and recommended by the Dutch Society of Pediatrics.     

Follow-up at age 10 years in ELBW children — Functional outcome,brain morphology and results from motor assessments in infancy

Background

Extremely-low-birth-weight (ELBW) children without severe brain injury or CP are at high risk of developing deficits within cognition, attention, behavior and motor function. Assessing the quality of an infant's spontaneous motor-repertoire included in Prechtl's General-Movement-Assessment (GMA) has been shown to relate to later motor and cognitive functioning in preterm children without CP.

Aims

To investigate functional outcome and cerebral MRI morphometry at 10 years in ELBW children without CP compared to healthy controls and to examine any relationship with the quality of infant-motor-repertoire included in the GMA.

Study design

A cohort-study-design.

Subjects

31 ELBW children (mean birth-weight: 773 g, SD 146, mean gestational age 26.1 weeks, SD 1.8) and 33 term-born, age-matched controls.

Outcome measures

GMA was performed in ELBW children at 3 months corrected age. At 10 years the children underwent comprehensive motor, cognitive, behavioral assessments and cerebral MRI.

Results

The non-CP ELBW children had similar full-IQ but poorer working memory, poorer motor skills, and more attentional and behavioral problems compared to controls. On cerebral MRI reduced volumes of globus pallidus, cerebellar white matter and posterior corpus callosum were found. Cortical surface-area was reduced in temporal, parietal and anterior-medial-frontal areas. Poorer test-results and reduced brain volumes were mainly found in ELBW children with fidgety movements combined with abnormal motor-repertoire in infancy.

Conclusion

Non-CP ELBW children have poorer functional outcomes, reduced brain volumes and cortical surface-area compared with term-born controls at 10 years. ELBW children with abnormal infant motor-repertoire seem to be at increased risk of later functional deficits and brain pathology.     

Circulating adipocyte fatty acid binding protein levels in healthy preterm infants: Positive correlation with weight gain and total-cholesterol levels

Background

Adipocyte fatty acid binding protein (a-FABP) has been suggested to play an important role in the pathogenesis of metabolic syndrome. Preterm infants are at risk for the later development of insulin resistance, and, possibly, other components of metabolic syndrome.

Aim

To determine circulating levels of a-FABP in preterm infants and examine possible associations of a-FABP with metabolic indices (serum lipids, glucose, and insulin levels, and homeostasis model assessment index of insulin resistance [HOMA-IR]), levels of leptin and adiponectin, anthropometric parameters and weight gain.

Study design

Prospective cohort study.

Subjects

55 healthy preterm (mean [SD] gestational age 32.8 [1.8] weeks) and 23 fullterm infants (reference group).

Outcome measures

Serum a-FABP, lipids, glucose, insulin, leptin and adiponectin levels at 31.9 [10.4] days of life.

Results

Serum a-FABP levels did not differ significantly between preterm and fullterm infants. A-FABP levels correlated positively with total-cholesterol [total-C] in both preterm and fullterm infants (β = 0.33; p = 0.01 and β = 0.33; p = 0.04, respectively). In addition to total-C, weight gain correlated independently with a-FABP levels in preterm infants (β = 0.36, p = 0.01).

Conclusions

An association between a-FABP levels and indices of insulin resistance was not present in infants studied. As the development of insulin resistance in children born prematurely is possibly associated with weight gain in early postnatal life, follow-up of our study population is necessary to demonstrate whether a-FABP levels, shown to correlate with weight gain in preterm infants, are a predictive marker for the later development of insulin resistance in these infants.     

Sensorimotor skills associated with motor dysfunction in children born extremely preterm

Background

Children born prematurely, despite being free of intellectual and sensorineural deficits, are at risk of motor dysfunction.

Aim

To investigate the association of sensorimotor processing skills and Developmental Coordination Disorder (DCD) in “apparently normal” extreme preterm children.

Study design

In a matched case-control study, 50 preterm children born less than 29 weeks or birthweight < 1000 g, with an IQ > 85 and no identified sensorineural disability, were assessed at 8 years of age along with 50 gender and birth date matched classroom controls born at full term. A battery of sensorimotor tests was administered, which examined visual-motor, visual perception, tactile perception, kinaesthesia, and praxis.

Results

For preterm children with DCD (n = 21), significantly lower scores were found for the visual processing and praxis tests, with the exception of verbal command, in comparison to those 29 preterm children without DCD and term controls (median visual perception scores were 92, 96 and 108 respectively; design copying was 0.07, 0.46 and 0.95; constructive praxis was 0.09, 0.27 and 0.63; and sequencing praxis was 0.14, 0.73 and 0.96). There were no difference on the tactile sensitivity and kinaesthetic processing tests.

Conclusions

Preterm children with DCD have difficulty with visual processing tasks. Praxis or motor planning poses a particular challenge for them. Motor dysfunction in extremely preterm children was related to poorer visual processing and motor planning and may relate to a cognitive processing problem.     

Motor impairment and low achievement in very preterm children at eight years of age

Aim

To examine the concurrence of motor impairment and academic underachievement in a group of very preterm children at 8 years of age.

Methods

All surviving children with a gestational age less than 30 weeks, admitted to the neonatal intensive care unit between 1987 and 1997, were prospectively enrolled in developmental follow-up. Children with a neurosensory disability or a low intelligence score (FSIQ ≤ 75 points) were excluded. At 8 years of age the Bruininks Oseretsky Test of Motor Proficiency and standardised tests of academic achievement were administered to a sample of 323 very preterm children.

Results

One hundred and one (31.3%) of these very preterm children were identified as having Developmental Coordination Disorder (DCD). Of the children with DCD, 54.4% also had underachievement in literacy and/or numeracy. As the severity of motor impairment increased so too did the severity and complexity of underachievement. Significantly fewer children with motor impairments participated in after-school sporting activities. Children with DCD required more mechanical ventilation support during their hospital admission.

Conclusions

This study demonstrated that a significant proportion of children born very preterm find both motor and academic skills difficult in early school years.     

Postnatal growth of preterm born children ≤ 750g at birth

Background

Extremely low birth weight (ELBW) infants are at risk of impaired postnatal growth. Impaired postnatal growth has been reported to be associated with delayed cognitive and motor development.

Aims

To describe postnatal growth patterns of appropriate and small for gestational age (AGA and SGA) ELBW children in relation to their cognitive and motor outcome at age 5.5.

Study design

Retrospective cohort study.

Subjects

One hundred one children with a BW ≤ 750 g, born between 1996 and 2005 in the University Hospital Utrecht, The Netherlands.

Outcome measures

Height (Ht), weight (Wt), occipital-frontal circumference (OFC) at birth, 15 months and 2 years corrected age and 3.5 and 5.5 years.Cognitive and motor outcome at 5.5 years of age, classified as normal (Z-score ≥−1), mildly delayed (−2 ≤ Z-score <−1) or severely delayed (Z-score <−2). AGA (Ht, Wt or OFC at birth ≥−2 SDS) infants were compared with SGA (Ht, Wt or OFC at birth <−2 SDS) infants.

Results

Between birth and 5.5 years catch-up growth in Ht, weight for height (Wt/Ht), Wt and OFC was seen in 72.2%, 55.2%, 28.6% and 68.9% respectively of the SGA infants. For AGA infants we found substantial catch-down growth in Ht (15.4%) and Wt (33.8%). Cognitive and motor outcome was normal in 76.2% and 41.6% of the 101 children. A significantly higher percentage of normal cognitive outcome was found in AGA infants with Wt growth remaining at ≥−2 SDS compared to AGA infants with catch-down growth (83% vs 63%). Next, SGA infants who caught-up in OFC had a higher prevalence of normal cognitive outcome compared to SGA infants who did not catch-up in OFC. Furthermore, a higher percentage of severely delayed motor outcome was found in SGA infants without catch-up growth in Wt compared to SGA infants who caught-up in Wt (61.5% vs 32.2%).

Conclusions

Catch-up growth in Ht, Wt/Ht and OFC occurred in the majority of the SGA infants with a BW ≤ 750 g, but was less common in Wt. AGA children who remained their Wt at ≥−2 SDS have a better cognitive and motor developmental outcome at 5.5 years of age. Catch-up growth in OFC was associated with a better cognitive outcome at 5.5 years of age.     

Predictive value of early motor evaluation in preterm very low birth weight and term small for gestational age children

Background

Motor problems are common in children born preterm or small for gestational age.

Aim

To study the predictive value of early motor assessments for later motor skills.

Subjects

Twenty-eight children born preterm with very low birth weight (VLBW: birth weight ≤ 1500 g), 57 children born small for gestational age (SGA: birth weight < 10th centile) at term and 77 term-born controls with normal birth weight.

Methods

The psychomotor development index (PDI) of the Bayley Scales of Infant Development was used as a measure of motor skills at age one, the Peabody Developmental Motor Scales (PDMS) at age five and the Movement Assessment Battery for Children (Movement ABC) at age 14. Low/borderline low scores were defined as < − 2SD/− 1SD (PDI) or < 5th/15th centile (PDMS; Movement ABC).

Results

In the VLBW group, motor problems in adolescence were identified both by low PDI (sensitivity: 0.80; 95%CI:0.38-0.96) and PDMS scores (sensitivity: 0.83; 95%CI:0.44-0.97). In the SGA and the control group sensitivity was poor for low PDI and moderate for low PDMS scores. However, in the SGA group, sensitivity increased when borderline low PDMS scores were used as cut-off (sensitivity: 0.75; 95%CI:0.41-0.93). Specificity of PDI and PDMS was high in all three groups.

Conclusions

Both PDI and PDMS may be valuable tools for early identification of motor problems in VLBW children, whereas PDMS best predicted motor problems in the two other groups. In all three groups, a normal motor examination at 1 and 5 years was highly predictive of normal motor skills at age 14.     

A comparison of executive function in very preterm and term infants at 8 months corrected age

Background

Executive function (EF) emerges in infancy and continues to develop throughout childhood. Executive dysfunction is believed to contribute to learning and attention problems in children at school age. Children born very preterm are more prone to these problems than their full-term peers.

Aim

To compare EF in very preterm and full-term infants at 8 months after expected date of delivery.

Subjects

37 very preterm infants without identified disabilities, and 74 gender and age matched healthy full-term infants. The very preterm infants were all ≤ 32 weeks gestation and < 1250 g birthweight.

Outcome measures

EF tasks which measured working memory, inhibition of distraction, and planning at 8 months after expected date of delivery.

Results

The very preterm infants performed significantly more poorly than the full-term infants on all measures of executive function. No significant differences were found between very preterm and full-term infants on any of potentially confounding variables of, infant temperament, maternal education, family income and maternal psychological wellbeing. Very preterm infants had significantly lower scores on the Mental Development Index (MDI) and Psychomotor Development Index (PDI) on the Bayley Scales of Infant Development (BSID II), however when this was partialled out the differences in EF scores remained. Medical complications, lower birthweight and lower gestation age were all found to adversely affect the performance of very preterm infants on executive function tasks.

Conclusion

Very preterm infants performed more poorly than full-term infants on measures of EF. Further follow up studies are required to investigate whether EF measures in infancy can predict learning and attention outcome at school age.     

Episodes of hypocarbia and early-onset sepsis are risk factors for cystic periventricular leukomalacia in the preterm infant

Background

Septic episodes in preterm infants recently have been reported to be associated with periventricular leukomalacia (PVL). The role of hypocarbia as an independent risk factor for PVL in clinical studies raises many questions without conclusive answers.

Aims

To evaluate risk factors for cystic PVL focussing on the influence of hypocarbia.

Study design

Retrospective single centre case-control study.

Subjects

Preterm infants 24 to 35 weeks of gestational age and matched (1:2 for gender, birth year, gestational age and birth weight) controls.

Outcome measures

Multivariate analysis of perinatal factors being associated with cystic PVL diagnosed by serial ultrasound examinations.

Results

Univariate analysis of risk factors revealed lower 5 and 10 min Apgar scores, and higher rates of neonatal seizures, early-onset sepsis, neonatal steroids, respiratory distress syndrome with surfactant replacement therapy, and episodes of hypocarbia significantly being associated with PVL. Multivariate analysis using a logistic regression model revealed early-onset sepsis and hypocarbia being significantly associated with PVL (p = .022 and .024, respectively). Lowest PaCO₂ values did not differ as did not the duration of hypocarbia, but the onset of hypocarbia was significantly later in PVL cases compared to controls (mean 26 vs. 15 h, p = .033). Neurodevelopmental follow-up at a median time of 46 months was poor showing 88% of the cases having an adverse neurological outcome.

Conclusion

We found early-onset sepsis and episodes of hypocarbia within the first days of life being independently associated with PVL.     

The link between sleep problems in infancy and early childhood and attention problems at 5 and 14 years: Evidence from a birth cohort study

Background

Little research has examined the associations between early sleep problems and attention problems over several developmental periods.

Aims

To examine whether sleep problems in infancy and early childhood are independently related to attention difficulty at 5 and 14 years, and to the continuity of attention difficulties from 5 to 14 years.

Study design

The study was a prospective, population-based birth cohort study.

Subjects

7223 women who delivered a live, singleton child between 1981 and 1983 were recruited at the first antenatal visit. Of these, 4204 had complete information on all key measures.

Outcome measures

Attention problems were assessed with items from the Child Behaviour Checklist (CBCL) and were classified as adolescent onset (i.e. problems at 14 but not at 5); early remitter (problems at 5, no problem at 14); and persistent (i.e. at both 5 and 14).

Results

At 6 months, sleep problems ‘sometimes’ were associated with the early remitter group in boys. For sleep problems between 2 and 4 years of age, findings were generally similar for boys and girls with strong associations with adolescent attention. Sleep problems ‘often’ were independently associated with early remitter and persistent attention problems, and ‘sometimes’ with early remitter and adolescent onset attention problems.

Conclusions

Sleep problems in early childhood are an indicator of subsequent attention problems that may persist into adolescence. Whether these associations are causal requires further research, however their presence provides an opportunity for early intervention and monitoring.     

Placental pathology is associated with illness severity in preterm infants in the first twenty-four hours after birth

Background

Placental pathology is associated with long-term neurological morbidity. Little is known about the association of placental pathology and illness severity directly after birth in preterm infants.

Objective

To determine the association between placental pathology and illness severity in preterm infants during the first 24 h after birth.

Study design

Placentas of 40 preterm infants, born after singleton pregnancies (gestational age 25.4-31.7 weeks, birth weight 560-2250 g) were assessed for histopathology. Illness severity was measured using the Score of Neonatal Acute Physiology Perinatal Extension (SNAPPE). A high SNAPPE reflects high illness severity.

Results

Examination of the 40 placentas revealed: pathology consistent with maternal vascular underperfusion (MVU) (n = 24), ascending intrauterine infection (AIUI) (n = 17), villitis of unknown aetiology (VUE) (n = 6), foetal thrombotic vasculopathy (FTV) (n = 6), elevated nucleated red blood cells (NRBCs) (n = 6), and chronic deciduitis (n = 10). SNAPPE ranged from 1 to 53 (median 10). Infants with elevated NRBCs had a higher SNAPPE than infants without elevated NRBCs (median 30 vs. 10, p = 0.014). The same was found for the presence of FTV (median 30 vs. 10, p = 0.019). No relation existed between SNAPPE and the other placental pathologies.

Conclusions

Elevated NRBCs and FTV were associated with higher illness severity during the first 24 h after birth in preterm infants. Ascending intrauterine infection was not associated with high illness severity.     

Support for the global feasibility of the Ages and Stages Questionnaire as developmental screener

Objective

To investigate the psychometric properties of the Dutch version of the 48 months Ages and Stages Questionnaire (D_ASQ_48).

Design

Prospective cohort study of a community-based sample of children born in 2002 and 2003 whose parents filled out the D_ASQ_48 and a questionnaire on school status at 60 months. The ASQ was translated into Dutch and back-translated into English by three independent translators.

Setting

Well Child Centers covering 25% of the Netherlands.

Participants

Parents of 1510 preterm and 562 term children born in 2002-2003 attending routine Well Child visits at age 45-50 months.

Main outcome measures

Reliability, validity and mean population scores for D_ASQ_48 compared to other countries.

Results

Mean population scores for the D_ASQ_48 were mostly similar to those in the USA, Norway and Korea. Exceptions (effect sizes of difference > 0.5) were problem solving (USA) and fine motor (Korea). Reliability was good for the total score (Cronbach alpha 0.79) and acceptable for all domains (0.61-0.74). As expected, infants born at gestational age < 32 weeks, children from low income families, of low educated mothers, and boys were more likely to fail on several domains (odds ratios, OR ranging from 1.5 to 4.9). The only unexpected association concerned children from one-parent families. Sensitivity to predict special education at five years of age was 89% and specificity 80%.

Conclusions

The good psychometric properties of the Dutch ASQ_48 and the small differences when compared to other countries support its usefulness in the early detection of developmental problems amongst children worldwide.     

Reduced cerebellar diameter in very preterm infants with abnormal general movements

Background

Abnormal General Movements (GMs) early in life are predictive of later neuromotor deficits and are related to white matter abnormalities on magnetic resonance imaging (MRI). However, other structural correlates of abnormal GMs have not been defined.

Aims

The objective of this study was to explore brain-metrics (linear brain measurements on MRI representative of 3-D brain volumes) at term as a predictor of abnormal GMs at 1 and 3 months' corrected age in preterm infants. It was hypothesized that abnormal GMs would be related to reduced brain-metrics in primary motor areas, namely the cerebellum and parietal lobes.

Study design

Eighty three preterm infants (< 30 weeks' gestational age) were scanned at term-equivalent age. MRI was assessed for white matter abnormality and brain-metrics in six predefined brain regions (i.e. bifrontal, biparietal, lateral ventricles and transverse cerebellar diameters, and inter-hemispheric distance).

Outcome measures

At 1 and 3 months' corrected age infants' GMs were assessed from video-taped footage and rated as normal or abnormal using standardized methodology.

Results

At 1 month, 63% (n = 52) of infants had abnormal GMs with no association between any of the brain-metrics and abnormal GMs. At 3 months, 23% (n = 18) of infants had abnormal GMs (absent fidgety movements n = 18; abnormal fidgety movements n = 0). Reduced bifrontal, biparietal, and cerebellar transverse diameters, along with an increase in lateral ventricle sizes were associated with an increased risk of abnormal GMs at 3 months' corrected age. After controlling for white matter abnormality and grade III/IV intraventricular haemorrhage, only the cerebellar transverse diameter was predictive of abnormal GMs at 3 months.

Conclusions

Reduced cerebellar diameter at term equivalent age is related to abnormal GMs at 3 months' corrected age, independent of white matter abnormality and intraventricular haemorrhage.     

Sepsis-associated electroencephalographic changes in extremely low gestational age neonates

Background

Sepsis in premature infants is associated with adverse neurodevelopmental outcomes. No previous studies have assessed acute changes in brain function during sepsis that might precede these adverse outcomes.

Methods

We performed amplitude-integrated electroencephalography (aEEG) monthly, from 28 weeks until 36 weeks of postmenstrual age, on 108 premature infants born before 28 weeks of gestation. Additional aEEG recordings were performed during infants' first episode of sepsis. Two independent readers who were blinded to the infant's gestational age at birth and chronologic age, as well as to whether the infant had sepsis, evaluated aEEG recordings for the presence of burst suppression and assigned a maturation score.

Results

Burst supression was found in 22% of aEEG recordings from infants without sepsis and 57% of recordings from infants with sepsis at the time of the recording (odds ratio = 4.2; 95% confidence limits = 2.4, 7.2; p < 0.001). After adjustment for postmenstrual age at the time of the recording, the association between sepsis and burst suppression persisted (odds ratio = 2.4; 95% confidence limits = 1.2, 4.8; p = 0.01). No statistically significant difference was found in the rate of increase in aEEG maturation score between infants with sepsis and those without.

Conclusion

Sepsis is associated with acute electroencephalographic changes, as indicated by burst supression, but not with a decreased rate of brain wave maturation.     

Motor trajectories from 4 to 18 months corrected age in infants born at less than 30 weeks of gestation

Background

Preterm infants are recognised as developing at a significantly slower rate than their full-term peers and with different movement quality.

Aim

This study aimed to describe the longitudinal gross motor trajectories of these infants in the first 18 months of (corrected) age and investigate factors associated with gross motor development.

Study design

A longitudinal study was conducted with convenience samples of 58 preterm infants born ≤ 29 weeks of gestation and 52 control full-term infants in Australia.

Outcome measures

The infants were assessed at 4, 8, 12 and 18 months of (corrected) age using the Alberta Infant Motor Scale (AIMS).

Results

Forty-six preterm and 48 control infants completed all four assessments. The preterm group scored significantly lower on various sub-scores at all age levels. Almost half of the preterm infants demonstrated less progression in the sit sub-scale from 4 to 8 months (corrected) age, possibly due to an imbalance between flexor and extensor strength in the trunk. At 12 and 18 months of (corrected) age, lack of rotation and fluency in their movements were evident in some preterm infants. Presence of intra-ventricular haemorrhage and chronic lung disease were associated with poor motor performance at 4 months and use of postnatal steroids was associated with poor motor performance at 4, 8 and 18 months of corrected age.

Conclusion

The imbalance between flexor and extensor muscle strength in preterm infants had a stronger impact on motor development than usually expected. The AIMS appears to be a sensitive assessment tool to demonstrate the unique movement characteristics in this preterm cohort.     

Hyperbilirubinemia in infants with Gram-negative sepsis does not affect mortality

Background

Sepsis is associated with an increased production of oxidant species and a decrease in endogenous antioxidant defenses. Mortality is high, especially when endotoxins are involved, e.g., in infants with Gram-negative sepsis. Yet, chronic as well as acute unconjugated hyperbilirubinemia has been shown to protect against endotoxin-induced shock in vivo in rats and in mice. We hypothesized that hyperbilirubinemia in infants with Gram-negative sepsis improves survival and/or mitigates the inflammatory response.

Objective

To assess the relationships between serum bilirubin concentrations on the one hand, and leukocyte count, C-reactive protein and survival on the other hand, in infants with Gram-negative sepsis.

Methods

Retrospectively, we retrieved clinical and biochemical data from infants less than 90 days of age with a blood culture-proven Gram-negative sepsis between January 1998 and December 2005.

Results

We identified 92 infants with Gram-negative sepsis in the indicated period. Median gestational age was 29 (24-42) weeks. 22 Patients died. Preceding sepsis, median total serum bilirubin concentrations were below 150 μmol/L. Median concentrations of conjugated bilirubin concentrations increased (+ 63%, p < 0.05), and median concentrations of unconjugated bilirubin decreased (− 36%, p < 0.05) in infants with Gram-negative sepsis. Median total bilirubin concentrations before and during sepsis were not significantly different between survivors and non-survivors. Changes in bilirubin concentrations were not significantly correlated with changes in either white blood cell count or C-reactive protein.

Conclusion

Present data do not support the concept that bilirubin positively affects survival or the inflammatory response in infants with Gram-negative sepsis.