Short-term outcome predictors in infants born at 23–24 gestational weeks

Aim: Outcome is uncertain in infants born at 23–24 gestational weeks. The aim of the present study was to identify possible early predictors of outcome in these infants.
Materials and Methods: Data from the Swedish medical birth register (MBR) for live-born infants with gestational ages (GAs) 23 and 24 weeks, born during the time-period 2000–2002, were analysed in relation to short-term outcomes, that is survival and survival without severe brain damage (intraventricular haemorrhage [IVH] grades 3 and 4 and/or periventricular leukomalacia [PVL]).
Results: In 57 infants born at 23 gestational weeks, survival was associated with birthweight (BW) (p = 0.018) and 5-min Apgar score (p = 0.020) on univariate analyses. In 99 infants born at 24 weeks of gestation, survival without severe brain damage correlated with BW (p = 0.039), birth type (singleton/multiple) (p = 0.017) and Apgar score at 1, 5 and 10 min (p = 0.028, 0.014 and 0.030, respectively). The best model for predicting survival without severe brain damage in infants born at 24 gestational weeks was based on 5-min Apgar score and birth type. The small number of live-born infants at 23 weeks of gestation did not allow for multiple logistic regression analyses.
Conclusion: The 5-min Apgar score is associated with short-term outcome in live-born infants at 23–24 gestational weeks. The association is stronger for infants born at 24 weeks of gestation.     

Short-term outcome predictors in infants born at 23-24 gestational weeks.

AIM: Outcome is uncertain in infants born at 23-24 gestational weeks. The aim of the present study was to identify possible early predictors of outcome in these infants. MATERIALS AND METHODS: Data from the Swedish medical birth register (MBR) for live-born infants with gestational ages (GAs) 23 and 24 weeks, born during the time-period 2000-2002, were analysed in relation to short-term outcomes, that is survival and survival without severe brain damage (intraventricular haemorrhage [IVH] grades 3 and 4 and/or periventricular leukomalacia [PVL]). RESULTS: In 57 infants born at 23 gestational weeks, survival was associated with birthweight (BW) (p = 0.018) and 5-min Apgar score (p = 0.020) on univariate analyses. In 99 infants born at 24 weeks of gestation, survival without severe brain damage correlated with BW (p = 0.039), birth type (singleton/multiple) (p = 0.017) and Apgar score at 1, 5 and 10 min (p = 0.028, 0.014 and 0.030, respectively). The best model for predicting survival without severe brain damage in infants born at 24 gestational weeks was based on 5-min Apgar score and birth type. The small number of live-born infants at 23 weeks of gestation did not allow for multiple logistic regression analyses. CONCLUSION: The 5-min Apgar score is associated with short-term outcome in live-born infants at 23-24 gestational weeks. The association is stronger for infants born at 24 weeks of gestation.     

Severe retinopathy of prematurity and its association with different rates of survival in infants of less than 1251 g birth weight

BACKGROUND: There is controversy over whether improved survival of preterm infants has resulted in a higher incidence of severe (grade 3 or greater) retinopathy of prematurity (ROP). AIM: To compare survival rates and rates of > or = stage 3 ROP-that is, with a high risk of sequelae-in preterm infants in five English cities where, anecdotally, the incidence of ROP is reported to show considerable variation. METHODS: All infants of birth weight < 1500 g and or gestational age < 32 weeks, born in 1994 in one of the cities or transferred in within 48 hours, were studied. The populations were adjusted for case mix variation using CRIB (clinical risk index for babies, a disease severity scoring system). The incidence of severe ROP, the actual death rate, and that adjusted for disease severity were determined. RESULTS: The rate of severe ROP per 1000 births was higher in city 1 than in all the other cities. This increase in comparison with city 2 and city 4 was significant (city 1, 167 (95% confidence interval (CI) 96 to 260); city 2, 24 (6 to 59); city 4, 16 (1 to 84)). A significant difference was not seen between city 1 and cities 3 (23 (1 to 120)) and 5 (74 (21 to 79)). The relative risk of developing severe ROP in city 1 compared with all the other cities was 5.5 (2.5 to 11.9). The actual death rate per 1000 births in city 1 was significantly lower than that predicted by modelling death against CRIB score (city 1: actual 270; predicted 385 (95% CI 339 to 431)). In contrast, the other cities had actual death rates as predicted, or worse than predicted, by CRIB. INTERPRETATION: A significantly higher incidence of severe ROP was identified in one of the five cities studied. Variation in survival rates among high risk infants may explain this observation.     

Effects of gestational age and prenatal and perinatal events on the coagulation status in premature infants

OBJECTIVE: To study prospectively the effects of prematurity and perinatal events on the coagulation status of premature infants. Patients and main outcome measures: Blood samples from premature infants born before 37 gestational weeks were taken for analysis of coagulation factors II, V, VII, and X and platelet count. RESULTS: A total of 125 premature infants, 71 boys, were studied at the median postnatal age of 40 minutes (range 12-100). The lowest median activities of coagulation factors II, V, VII, and X and the platelet count were observed, as expected, in infants (n = 21) born at 24-27 weeks gestation. Twin B (n = 14) had lower median activities of coagulation factors II, V, VII, and X than twin A. Infants with evidence of mild asphyxia (Apgar score at 5 minutes < 7 or cord pH < 7.26) had significantly (p < 0.05) lower levels of coagulation factors II, V, VII, and X and platelet counts than infants without asphyxia. Infants who were small for gestational age (SGA) had significantly (p < 0.05) lower levels of coagulation factors V and VII and platelet counts than infants of appropriate size for gestational age. Other prenatal and perinatal variables examined (sex, maternal hypertension and/or pre-eclampsia, antenatal steroid use, mode of delivery, Apgar scores) did not show any significant associations with coagulation status, which may be explained by the small number of infants studied. CONCLUSIONS: The data strongly suggest that there are distinct differences in specific coagulation tests in different patient populations, which could assist in the identification of extremely preterm, SGA, or asphyxiated preterm infants who may be susceptible to haemorrhagic problems perinatally.     

极早产儿存活率和并发症的多中心回顾性研究

目的 研究极早产儿存活率和严重并发症发生情况,并分析其影响因素。 方法 回顾性收集2018年1月至2019年12月江苏省11家医院新生儿科收治的极早产儿（胎龄<32周）的一般资料,分析其存活率和严重并发症发生情况,采用多因素logistic回归分析评估极早产儿死亡和严重并发症发生的危险因素。 结果 共纳入极早产儿2 339例,其中存活2 010例（85.93%）,无严重并发症存活1 507例（64.43%）。胎龄22~25⁺⁶周、26~26⁺⁶周、27~27⁺⁶周、28~28⁺⁶周、29~29⁺⁶周、30~30⁺⁶周、31~31⁺⁶周各组极早产儿存活率分别是32.5%、60.6%、68.0%、82.9%、90.1%、92.3%、94.8%,随着胎龄增加,存活率呈升高趋势（P<0.05）;相同胎龄分组下无严重并发症存活率分别是7.5%、18.1%、34.5%、52.2%、66.7%、75.7%、81.8%,随着胎龄增加,无严重并发症存活率呈升高趋势（P<0.05）。多因素logistic回归分析显示,胎龄大、出生体重大、母亲产前使用糖皮质激素是极早产儿死亡的保护因素（P<0.05）,而1 min Apgar评分≤3分是极早产儿死亡的危险因素（P<0.05）;胎龄大、出生体重大是存活极早产儿发生严重并发症的保护因素（P<0.05）,而5 min Apgar评分≤3分、母亲绒毛膜羊膜炎是存活极早产儿发生严重并发症的危险因素（P<0.05）。 结论 极早产儿存活率与胎龄密切相关。1 min Apgar评分≤3分可增加极早产儿死亡的风险,而胎龄大、出生体重大、母亲产前使用糖皮质激素与死亡风险降低有关。5 min Apgar评分≤3分和母亲绒毛膜羊膜炎可增加极早产儿严重并发症发生的风险,而胎龄大、出生体重大可降低严重并发症发生的风险。     

Survival of very preterm infants: Epipage, a population based cohort study

OBJECTIVE: To evaluate the outcome for all infants born before 33 weeks gestation until discharge from hospital. DESIGN: A prospective observational population based study. SETTING: Nine regions of France in 1997. PATIENTS: All births or late terminations of pregnancy for fetal or maternal reasons between 22 and 32 weeks gestation. MAIN OUTCOME MEASURE: Life status: stillbirth, live birth, death in delivery room, death in intensive care, decision to limit intensive care, survival to discharge. RESULTS: A total of 722 late terminations, 772 stillbirths, and 2901 live births were recorded. The incidence of very preterm births was 1.3 per 100 live births and stillbirths. The survival rate for births between 22 and 32 weeks was 67% of all births (including stillbirths), 85% of live births, and 89% of infants admitted to neonatal intensive care units. Survival increased with gestational age: 31% of all infants born alive at 24 weeks survived to discharge, 78% at 28 weeks, and 97% at 32 weeks. Survival among live births was lower for small for gestational age infants, multiple births, and boys. Overall, 50% of deaths after birth followed decisions to withhold or withdraw intensive care: 66% of deaths in the delivery room, decreasing with increasing gestational age; 44% of deaths in the neonatal intensive care unit, with little variation with gestational age. CONCLUSION: Among very preterm babies, chances of survival varies greatly according to the length of gestation. At all gestational ages, a large proportion of deaths are associated with a decision to limit intensive care.     

Use of the CRIB (clinical risk index for babies) score in prediction of neonatal mortality and morbidity.

A prospective study of the outcome of care of a regional cohort of very low birthweight (< 1500 g) and very preterm (< 32 weeks) infants was carried out. Its aims were to assess the ability of the CRIB (clinical risk index for babies) score, rather than gestational age or birthweight, to predict mortality before hospital discharge, neurological morbidity, and length of stay, and to access CRIB score as an indicator of neonatal intensive care performance. 676 live births fulfilled the criteria and complete data were available for 643 (95%). Compared with gestation and birthweight, CRIB was better for the prediction of mortality, was as good for the prediction of morbidity, and was not as good for the prediction of length of stay. CRIB adjusted mortality did not demonstrate better performance in units providing the highest level of care. Either the CRIB score was not sensitive to performance or the level 3 hospitals in this study were performing badly. On the basis of this analysis purchasers and providers of neonatal intensive care cannot yet rely on the CRIB score as a performance indicator.     

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 amplitude-integrated EEG correlates with cord TNF-α and brain injury in very preterm infants

Aim: To investigate if the early electroencephalogram (EEG) and amplitude-integrated EEG (aEEG) in very preterm infants is affected by perinatal inflammation and brain injury, and correlates with long-term outcome.
Methods: Sixteen infants born at 24–28 gestational weeks (median 25.5) had continuous EEG/aEEG during the first 72 h of life. Minimum and maximum EEG interburst intervals (IBI), and aEEG amplitudes were semi-automatically quantified and averaged over the recording period. Neonatal brain injury was diagnosed with repeated cranial ultrasound investigations. Nine cytokines from four time-points were analyzed during the first 72 h (umbilical cord blood, 6, 24 and 72 h), and outcome was assessed at 2 years of corrected age.
Results: Infants with neonatal brain injury (n = 9) had prolonged IBI, 11.8 (9.6–23.2) sec versus 8.2 (7.1–11.6) sec in infants (n = 7) without brain damage (p = 0.005). Handicap at 2 years (n = 8, including two infants without neonatally diagnosed brain injury) was associated with prolonged neonatal IBI and lower aEEG amplitudes. Also aEEG amplitudes were decreased in infants with neonatal brain injury. There was a significant positive correlation between the averaged IBI and cord blood TNF-α (rs = 0.595, p = 0.025).
Conclusion: Early EEG depression is associated with increased cord blood TNF-α, neonatal brain damage and handicap at 2 years.     

Five‐year survival without major disability of extremely preterm infants born at 22–27 weeks’ gestation admitted to a NICU

Aim: To compare the 5‐year survival without major disability in infants born at the threshold of viability at 22–25 weeks who were actively treated in the delivery room and admitted to a NICU to that of those born at 26–27 weeks of gestation. Methods: All infants between 22⁺⁰ and 27⁺⁶ weeks of gestation admitted to a regional intensive care unit during 1999–2003 were enroled prospectively. The survival and major disability at 5 years of age were analysed by gestational age. Results: Of 242 treated infants, 202 survived (83.5%). Although the overall survival rate was significantly higher in the 25–27 weeks’ gestation infants than the 22–24 weeks’ gestation infants (p < 0.001), the survival rate among infants 22–24 weeks (63.6%, 63.6%, and 70%) did not significantly differ, likewise infants 25–27 weeks (88.7%, 90.6%, and 92%) had similar results. Overall, 28 children (14.4% of assessed) had major disability. Both survival and survival without major disability were positively influenced by increasing gestational age, increasing birth weight, being born at 25–27 weeks and being female child. Conclusion: With an active approach in treatment, the outcome of infants born at 25 weeks is comparable to those born at 26–27 weeks. Thus, the ‘grey zone’ in which the risk of adverse outcome is high narrows to 22–24 weeks.     

Early amplitude-integrated EEG correlates with cord TNF-alpha and brain injury in very preterm infants.

AIM: To investigate if the early electroencephalogram (EEG) and amplitude-integrated EEG (aEEG) in very preterm infants is affected by perinatal inflammation and brain injury, and correlates with long-term outcome. METHODS: Sixteen infants born at 24-28 gestational weeks (median 25.5) had continuous EEG/aEEG during the first 72 h of life. Minimum and maximum EEG interburst intervals (IBI), and aEEG amplitudes were semi-automatically quantified and averaged over the recording period. Neonatal brain injury was diagnosed with repeated cranial ultrasound investigations. Nine cytokines from four time-points were analyzed during the first 72 h (umbilical cord blood, 6, 24 and 72 h), and outcome was assessed at 2 years of corrected age. RESULTS: Infants with neonatal brain injury (n=9) had prolonged IBI, 11.8 (9.6-23.2) sec versus 8.2 (7.1-11.6) sec in infants (n=7) without brain damage (p=0.005). Handicap at 2 years (n=8, including two infants without neonatally diagnosed brain injury) was associated with prolonged neonatal IBI and lower aEEG amplitudes. Also aEEG amplitudes were decreased in infants with neonatal brain injury. There was a significant positive correlation between the averaged IBI and cord blood TNF-alpha (rs=0.595, p=0.025). CONCLUSION: Early EEG depression is associated with increased cord blood TNF-alpha, neonatal brain damage and handicap at 2 years.     

Neurodevelopmental outcome of preterm very low birth weight infants born from 2005 to 2007

ObjectiveTo evaluate short-term neurodevelopmental outcome (at 24 months of corrected age) and correlations with obstetric and neonatal factors in a sample of preterm very low birth weight infants born and admitted to an Italian tertiary centre between 2005 and 2007.Methods156 infants with a birth weight ≤ 1500 g (gestational age, range: 27–31 weeks) were followed at regular intervals through neurodevelopmental (neurological and psychomotor) assessment up to 24 months of corrected age. A statistical analysis was conducted in order to look for correlations between pre- and perinatal variables and neuropsychomotor outcome at 24 months.Results131 children were classified as normal and the other 25 presented sequelae classified as “minor” in 17 cases and as “major” in eight. The most significant risk factors for a poor outcome were preterm premature rupture of the membranes, bronchodysplasia, late-onset sepsis, postnatal steroid therapy and male gender. The presence of severe abnormalities on brain ultrasound scan and of an abnormal neurological assessment at 40 weeks at term equivalent age were strong predictors of poor outcome.ConclusionsOur study is one of the few investigating the short-term outcome of preterm VLBW Italian children born in the second half of the 2000s. Neurodevelopmental assessment at 24 months revealed a marked reduction in major sequelae. Several risk factors for a poor neurodevelopmental outcome identified in children born in earlier periods were confirmed in these children born in recent years.     

Umbilical cord levels of interleukin-1 receptor antagonist and neonatal outcome

BACKGROUND: Previous studies indicate that there may be infant gender differences in cytokine expression associated with differences in neonatal morbidity. OBJECTIVE: We tested the hypothesis that umbilical cord interleukin-1 receptor antagonist (IL-1ra) correlates with infant gender and neonatal outcome in preterm infants. STUDY DESIGN: IL-1ra was measured in cord blood taken from 58 preterm infants (33 males, 25 females) with gestational age less than 32 weeks. Receiver operating characteristics (ROC) curve were used for identifying IL-1ra values with high sensitivity and specificity for neonatal morbidity and adverse outcome, i.e., death or survival with severe intraventricular hemorrhage or periventricular leukomalacia. RESULTS: In the female infants, but not the male infants, cord IL-1ra values correlated with postnatal depression, expressed as Apgar scores at 1 min (correlation coefficient, r(s); p value: -0.542; 0.005), 5 min (-0.571; 0.018), and 10 min (-0.442; 0.035); and postnatal age at intubation (-0.799; 0.001). The ROC area under the curve (AUC) was 0.735 for adverse outcome (p=0.013), and 0.683 for bronchopulmonary dysplasia (p=0.021) when all infants were included. However, there was a significant gender difference in the ROC curve for adverse outcome (p=0.026), with AUC 0.640 (p=0.240) in males and AUC 0.929 (p=0.008) in females. Above a chosen cutoff at 13,500 ng/l for IL-1ra cord the sensitivity and specificity for predicting adverse outcome was 100 and 81%, respectively in females versus 50 and 84% in males. CONCLUSION: Increased levels of cord IL-1ra levels are associated with neonatal morbidity and adverse outcome in preterm infants. Comparable levels of IL-1ra have different predictive value depending on infant gender.     

Factors associated with successful establishment of breastfeeding in very preterm infants

Aim: To describe feeding practices at hospital discharge in relation to characteristics of the very preterm infants (VPI) and their mothers. Methods: Design. Prospective hospital‐based registration of very preterm infants born with a gestational age ≤32 weeks in Denmark during 2004–2008. Subjects. Healthy mothers and VPI without diseases causing eating disabilities at discharge. Results: A total of 478 VPI were registered. At discharge, 60% were exclusively breastfed, 35% were exclusively bottlefed, and 5% were both breast‐ and bottle‐fed. Mothers of high social class (p = 0.000) and ‘not smoking’ (p = 0.003) were significantly more often breastfeeding their preterm infant(s) at discharge. Single births infants tended more often to be breastfed (p = 0.09). Infant age at discharge and duration of hospitalization did not influence breastfeeding at discharge. Increase in weight z‐score from birth to discharge was largest in the bottlefeeding‐group compared with the breastfeeding‐group (p = 0.000) probably as a result of feeding practice the last week(s) of hospitalization. Conclusion: Breastfeeding can successfully be established in very preterm infants. Mothers of low social classes, smokers, multiple birth and very preterm infants with low weight for age may need extra attention in breastfeeding establishing policies.     

The nonimpact of gestational age on neurodevelopmental outcome for ventilated survivors born at 23-28 weeks of gestation

Aim: It has long been known that survival of preterm infants strongly depends upon birth weight and gestational age. This study addresses a different question – whether the gestational maturity improves neurodevelopmental outcomes for ventilated infants born at 23–28 weeks who survive to neonatal intensive care unit (NICU) discharge. Methods: We performed a prospective cohort study of 199 ventilated infants born between 23 and 28 weeks of gestation. Neurodevelopmental impairment was determined using the Bayley Scales of Infant Development‐II at 24 months. Results: As expected, when considered as a ratio of all births, both survival and survival without neurodevelopmental impairment were strongly dependent on gestational age. However, the percentage of surviving infants who displayed neurodevelopmental impairment did not vary with gestational age for any level of neurodevelopmental impairment (MDI or PDI <50, <60, <70). Moreover, as a higher percentage of ventilated infants survived to NICU discharge at higher gestational ages, but the percentage of neurodevelopmental impairment in NICU survivors was unaffected by gestational age, the percentage of all ventilated births who survived with neurodevelopmental impairment rose – not fell – with increasing gestation age. Conclusion: For physicians, parents and policy‐makers whose primary concern is the presence of neurodevelopmental impairment in infants who survive the NICU, reliance on gestational age appears to be misplaced.     

Neonatal mortality and morbidity in preterm infants born from assisted reproductive technologies

Aim: Premature birth is frequent in infants conceived with assisted reproductive technologies (ART). We sought to determine whether neonatal outcome in ART preterm infants differs from that of spontaneously conceived (SC) preterm infants. Methods: Data were prospectively collected in infants born ≤32 weeks after ART or SC. We calculated a composite index of severe morbidity (based on occurrences of severe necrotizing enterocolitis, severe intraventricular haemorrhage, periventricular leukomalacia or bronchopulmonary dysplasia). Survival rate without severe morbidity was compared between the two groups. Results: Six hundred and twelve preterm infants were hospitalized in our tertiary care centre: 81 in ART group and 521 in SC group. In the ART group, twin pregnancy (69.1% vs. 15.9%, p < 0.001) and inborn delivery (98.8% vs. 90.0%, p < 0.01) were more frequent. Gestational age (29 vs. 28 weeks, p < 0.05) and birth weight (1100 vs. 1020 g, p < 0.001) were also higher. Survival without severe morbidity was significantly higher in ART infants (76.5% vs. 55.2%, p < 0.001), with the difference mainly observed in infants born ≤28 weeks (22.9% vs. 55.7%, p < 0.001). Conclusion: Assisted reproductive technologies was not associated with adverse neonatal outcome. Differences in pregnancy and neonatal characteristics probably explain the increased survival without severe morbidity in ART infants.     

Brain abnormalities in extremely low gestational age infants: a Swedish population based MRI study

AIMS: Brain abnormalities are common in preterm infants and can be reliably detected by magnetic resonance (MR) imaging at term equivalent age. The aim of the present study was to acquire population based data on brain abnormalities in extremely low gestational age (ELGA) infants from the Stockholm region and to correlate the MR findings to perinatal data, in order to identify risk factors. METHODS: All infants with gestational age <27 weeks, born in the Stockholm region between January 2004 and August 2005, were scanned on a 1.5 T MR system at term equivalent age. Images were analysed using a previously established scoring system for grey and white matter abnormalities. RESULTS: No or only mild white matter abnormalities were observed in 82% and moderate to severe white matter abnormalities in 18% of infants. The Clinical Risk Index for Babies (CRIB II) score, use of inotropes, the presence of high-grade intraventricular haemorrhages and posthaemorrhagic ventricular dilatation were associated with white matter abnormalities. CONCLUSION: The incidence of moderate to severe white matter abnormalities in a population-based cohort of ELGA infants from the Stockholm region was 18%. To examine the clinical relevance of these promising results, neurodevelopmental follow up at 30 month corrected age, is ongoing.     

Neonatal intensive care at borderline viability--is it worth it?

BACKGROUND: Very preterm infants at the borderline of viability, especially those <25 weeks of gestational age, have survived in increasing numbers in recent years, but concerns persist about their long-term outcome and their consumption of scarce hospital resources. AIMS: To determine incremental changes in long-term outcome and consumption of resources by very preterm infants in the 1990s. DESIGN: Cohort study. PATIENTS: Consecutive livebirths with gestational ages 23-27 weeks born in the state of Victoria in two discrete eras, 1991-1992 (n=401) and 1997 (n=208), and randomly selected contemporaneous normal birthweight (NBW, birthweight >2499 g) controls (1991-1992 n=265, 1997 n=198). MAIN OUTCOME MEASURES: Survival, and neurosensory impairments, disabilities and utilities, and consumption of hospital resources to 2 years of age. RESULTS: Compared with 1991-1992, in 1997 more infants were offered intensive care and the survival rate was higher at each week of gestation, and overall (absolute increase in survival 16%; 95% confidence interval, 8%, 24%). The largest increases in the survival and quality-adjusted survival rates were in infants at 23 weeks (31% and 20%, respectively). The incremental resource costs of improving survival and quality-adjusted survival were similar in infants of 23-24 weeks compared with those of 25-27 weeks (e.g., 112 vs. 105 days of assisted ventilation per additional survivor, or 167 vs. 180 days of assisted ventilation per additional quality-adjusted survivor, respectively). CONCLUSIONS: Increased intensive care in the late 1990s for infants at the borderline of viability was associated with improved outcomes, at incremental costs that were not excessive compared with slightly more mature infants.     

Urinary S-100B concentrations in term and preterm infants at risk for brain damage

BACKGROUND: Elevated serum concentrations of S-100B, a 21-kDa protein expressed in astroglial cells, has been used to assess cerebral damage after head trauma, infection, ischemia, and perinatal asphyxia. OBJECTIVE: As S-100B is eliminated by the kidneys, we investigated the feasibility of measuring S-100B in urine of newborns with severe perinatal asphyxia, and in very low birth weight (VLBW) preterm infants at risk for neurodevelopmental impairment. METHODS: We first analyzed urine samples of 8 term or near-term newborns without major medical problems, followed by urine samples of 2 term newborns with severe birth asphyxia, and finally urine samples of 8 VLBW (gestational age 24-28 weeks) infants collected every 4 h for up to 10 days. RESULTS: Urinary S-100B concentrations in 8 term or near-term newborns without major medical problems were consistently <1 microg/l. In 2 term newborns with severe asphyxia (Apgar 0/0/0 and 0/2/4) who subsequently had widespread cerebral damage on magnetic resonance imaging, peak urinary S-100B concentrations on the first day of life were 28.1 and 28.4 microg/l, respectively. In 5/8 VLBW infants, urinary S-100B was> microg/l in samples obtained on the first day of life (range 1.2-44.9 microg/l, median 6.8 microg/l). Peak S-100B in urine samples collected during the first 12 h of life were negatively related to gestational age (R(s)=-0.882, p=0.009). Three of the 8 preterm infants had peak urinary concentrations>0 microg/l but neither ultrasound signs of brain damage nor neurodevelopmental delay at 1 year corrected age. CONCLUSIONS: The determination of urinary S-100B concentrations might be helpful in term infants with severe asphyxia, while high urinary S-100B concentrations in preterm infants are to be attributed to immaturity.     

Neurodevelopmental outcome of infants with birth asphyxia treated with magnesium sulfate

BACKGROUND: A neuroprotective effect of MgSO(4) has been shown in some animal models of perinatal hypoxic-ischemic brain damage. The aim of the present paper was to determine whether postnatal MgSO(4) infusion (250 mg/kg per day i.v. for 3 days, in combination with dopamine) is safe in infants with severe birth asphyxia, and also observe effects on neurodevelopmental outcome at 18 months. METHODS: Inclusion criteria were clinical history consistent with perinatal asphyxia; gestational age at least 37 weeks; 5 min Apgar score < or =6; failure to initiate spontaneous respiration within 10 min after birth; and symptoms of encephalopathy. On each day MgSO(4) was infused over 1 h in combination with dopamine (5 microg/kg per min). Changes in vital signs, clinical course of encephalopathy, laboratory variables, and adverse events were monitored. Infants were followed for 18 months. RESULTS: Thirty infants were studied. Mean birthweight was 2878 g; mean gestational age, 39.6 weeks, and median 5 min Apgar score, 3. All required endotracheal intubation for resuscitation. Median age at MgSO(4) initiation was 5 h. All infants had moderate or severe hypoxic-ischemic encephalopathy. Mean serum Mg(2+) concentration remained at least 1.3 mmol/L. MgSO(4) caused no change in physiological variables including mean arterial pressure. Two infants died as neonates, while six of 28 survivors had severe neurodevelopmental disability at 18 months; the remaining 22 had no neurodevelopmental disability. CONCLUSION: Postnatal infusion of MgSO(4) with dopamine caused no change in physiological variables. Deaths and severe sequelae were less frequent than in reported cases with the same grade of hypoxic-ischemic encephalopathy severity, and this treatment may improve neurodevelopmental outcome in infants with severe birth asphyxia.