Transition of extremely low-birth-weight infants from adolescence to young adulthood: comparison with normal birth-weight controls

Context  Traditionally, educational attainment, getting a job, living independently, getting married, and parenthood have been considered as markers of successful transition to adulthood. Objective  To describe and compare the achievement and the age at attainment of the above markers between extremely low-birth-weight (ELBW) and normal birth-weight (NBW) young adults. Design, Setting, and Participants  A prospective, longitudinal, population-based study in central-west Ontario, Canada, of 166 ELBW participants who weighed 501 to 1000 g at birth (1977-1982) and 145 sociodemographically comparable NBW participants assessed at young adulthood (22-25 years). Interviewers masked to participant status administered validated questionnaires via face-to-face interviews between January 1, 2002, and April 30, 2004. Main Outcome Measures  Markers of successful transition to adulthood, including educational attainment, student and/or worker role, independent living, getting married, and parenthood. Results  At young adulthood, 149 (90%) of 166 ELBW participants and 133 (92%) of 145 NBW participants completed the assessments at mean (SD) age of 23.3 (1.2) years and 23.6 (1.1) years, respectively. We included participants with neurosensory impairments (ELBW vs NBW: 40 [27%] vs 3 [2%]) and 7 proxy respondents. The proportion who graduated from high school was similar (82% vs 87%, P = .21). Overall, no statistically significant differences were observed in the education achieved to date. A substantial proportion of both groups were still pursuing postsecondary education (47 [32%] vs 44 [33%]). No significant differences were observed in employment/school status; 71 (48%) ELBW vs 76 (57%) NBW young adults were permanently employed (P = .09). In a subanalysis, a higher proportion of ELBW young adults were neither employed nor in school (39 [26%] vs 20 [15%], P = .02 by Holm's correction); these differences did not persist when participants with disabilities were excluded. No significant differences were found in the proportion living independently (63 [42%] vs 70 [53%], P = .19), married/cohabitating (34 [23%] vs 33 [25%], P = .69), or who were parents (16 [11%] vs 19 [14%], P = .36). The age at attainment of the above markers was similar for both cohorts. Conclusion  Our study results indicate that a significant majority of former ELBW infants have overcome their earlier difficulties to become functional young adults.      

Indirect vs direct hospital quality indicators for very low-birth-weight infants

Context  Evidence-based selective referral strategies are being used by an increasing number of insurers to ensure that medical care is provided by high-quality providers. In the absence of direct-quality measures based on patient outcomes, the standards currently in place for many conditions rely on indirect-quality measures such as patient volume. Objectives  To assess the potential usefulness of volume as a quality indicator for very low-birth-weight (VLBW) infants and compare volume with other potential indicators based on readily available hospital characteristics and patient outcomes. Design, Setting, and Participants  A retrospective study of 94 110 VLBW infants weighing 501 to 1500 g born in 332 Vermont Oxford Network hospitals with neonatal intensive care units between January 1, 1995, and December 31, 2000. Main Outcome Measures  Mortality among VLBW infants prior to discharge home; detailed case-mix adjustment was performed by using patient characteristics available immediately after birth. Results  In hospitals with less than 50 annual admissions of VLBW infants, an additional 10 admissions were associated with an 11% reduction in mortality (95% confidence interval [CI], 5%-16%; P<.001). The annual volume of admissions only explained 9% of the variation across hospitals in mortality rates, and other readily available hospital characteristics explained an additional 7%. Historical volume was not significantly related to mortality rates in 1999-2000, implying that volume cannot prospectively identify high-quality providers. In contrast, hospitals in the lowest mortality quintile between 1995 and 1998 were found to have significantly lower mortality rates in 1999-2000 (odds ratio [OR], 0.64; 95% CI, 0.55-0.76; P<.001) and hospitals in the highest mortality quintile between 1995 and 1998 had significantly higher mortality rates in 1999-2000 (OR, 1.37; 95% CI, 1.16-1.64; P<.001). The percentage of hospital-level variation in mortality in 1999-2000 that was forecasted by the highest and lowest quintiles based on patient mortality was 34% compared with only 1% for the highest and lowest quintiles of volume. Conclusions  Referral of VLBW infants based on indirect-quality indicators such as patient volume may be minimally effective. Direct measures based on patient outcomes are more useful quality indicators for the purposes of selective referral, as they are better predictors of future mortality rates among providers and could save more lives.      

极低出生体重儿的早期全静脉营养的临床探讨

目的:观察早期大量快速静脉营养和晚期小量静脉营养对极低出生体重儿(VLBW)能量代谢的影响.方法:将63例VLBW患儿随机分成两组,早期全静脉营养(ETPN)于生后24 h内给予2.0 g/(kg·天)的氨基酸和1.5 g(kg·天)的20%脂肪乳,之后每天增加1.0 g/kg;晚期全静脉营养(LTPN)于生后24～48 h开始给予氨基酸0.5 g/(kg·天),48～72 h开始给予20%脂肪乳0.5 g/(kg·天),按0.5 g/(kg·天)递增.两组目标剂量均为氨基酸3.5 g/(kg·大),20%脂肪乳3.0 g/(kg·天).观察比较两组患儿氮平衡,能量摄入,同时比较胆固醇、甘油三酯、胆红素、肌酐、血糖等生化指标.结果:ETPN组在氮储存上明显高过LTPN组(P<0.01),生后1～5天的能量摄入亦明显升高(P<0.01).两组在胆固醇、甘油三酯、胆红素、肌酐上无明显区别.LTPN组的血糖水平较ETPN组明显升高(P>0.05).结论:早期全静脉营养可以避免负氮平衡,增加热卡供给,且对早期预后没有明显不良反应.     

Vasculopathic hepatotoxicity associated with E-Ferol syndrome in low-birth-weight infants

A fatal syndrome characterized by progressive clinical deterioration with unexplained thrombocytopenia, renal dysfunction, cholestasis, and ascites developed in certain infants throughout the United States who had received E-Ferol, an intravenous vitamin E supplement. We reviewed the clinical course of all 36 infants from one (index) nursery who had received E-Ferol, which contains 25 units per milliliter of dl-alpha-tocopheryl acetate solubilized with 9% polysorbate 80 and 1% polysorbate 20. The syndrome was recognized in eight of the 36 infants; affected infants had a lower birth weight (less than 1,200 g) and had received a higher total dose of E-Ferol for longer periods than the unaffected cases. We reviewed autopsy-derived tissue from 20 infants (six from the index nursery and 14 from three other collaborating nurseries) who had received the intravenous vitamin E preparation in a reported dose of 25 to 137 units/kg/day for six to 45 days between October 1983 and March 1984. The hepatic histology in the affected cases indicated a progressive injury characterized initially by Kupffer cell exfoliation, central lobular accumulation of cellular debris, and centrally accentuated panlobular congestion. Prolonged exposure to E-Ferol was associated with progressive intralobular cholestasis, inflammation of hepatic venules, and extensive sinusoidal veno-occlusion by fibrosis. We propose that vasculocentric hepatotoxicity is the basis for the observed clinical syndrome that represents the cumulative effect of one or more of the constituents of E-Ferol.     

Change in cognitive function over time in very low-birth-weight infants

Context  Preterm very low-birth-weight (VLBW) infants have a high prevalence of neurodevelopmental disability when evaluated during the first several years of life. However, recent experimental data suggest that the developing brain may recover from or compensate for injury. Objective  To determine if there is cognitive improvement throughout early and middle childhood following VLBW birth. Design, Setting, and Participants  Follow-up data of 296 infants born weighing 600 to 1250 g who participated in a prospective, randomized, placebo-controlled intraventricular hemorrhage (IVH) prevention study performed at 3 northeastern US hospitals between September 1989 and August 1992 and who were serially evaluated at 36, 54, 72, and 96 months of corrected age (CA). Main Outcome Measures  The age-normed Peabody Picture Vocabulary Test–Revised (PPVT-R) score and measures of intelligence. Results  Overall, the median PPVT-R score increased from 88 at 36 months of CA to 99 at 96 months of CA; when data from 36 and 96 months of CA were compared, 45% of children gained 10 points or more and 12.5% showed a 5- to 9-point increase in test scores. Similar findings were noted for full-scale and verbal IQ scores. Multivariate analyses demonstrated that increasing age, residence in a 2-parent household, and higher levels of maternal education were all significantly associated with higher PPVT-R scores (for each, P<.001). In addition, early intervention led to greater increases over time in PPVT-R scores among children whose mothers had less than a high school education compared with those with a high school education level or greater (P = .03 by test for interaction). Although most children showed improvement in PPVT-R scores with increasing CA, children with early-onset IVH and subsequent significant central nervous system injury had the lowest PPVT-R scores initially and the scores declined over time (P = .009 by test for interaction). Conclusions  The majority of VLBW children had improvement in verbal and IQ test scores over time. Only children with early-onset IVH followed by significant central nervous system injury had low PPVT-R scores that declined over time.      

Contributing death factors in very low-birth-weight infants by path method analysis

Background:

Neonatal deaths account for 40% of deaths under the age of 5 years worldwide. Therefore, efforts to achieve the UN Millennium Development Goal 4 of reducing childhood mortality by two-thirds by 2015 are focused on reducing neonatal deaths in high-mortality countries. The aim of present study was to determine death factors among very low-birth-weight infants by path method analysis.

Materials and Methods:

In this study, medical records of 2,135 infants admitted between years 2008 and 2010 in neonatal intense care unit of Alzahra Educational-Medical centre (Tabriz, Iran) were analysed by path method using statistical software SPSS 18.

Results:

Variables such as duration of hospitalisation, birth weight, gestational age have negative effect on infant mortality, and gestational blood pressure has positive direct effect on infant mortality that at whole represented 66.5% of infant mortality variance (F = 1018, P < 0.001). Gestational age termination in the positive form through birth weight, and also gestational blood pressure in negative form through hospitalisation period had indirect effect on infant mortality.

Conclusion:

The results of the study indicated that the duration of low-birth-weight infant''s hospitalisation is also associated with infant''s mortality (coefficient -0.7; P < 0.001). This study revealed that among the maternal factors only gestational blood pressure was in relationship with infants’ mortality.     

2709例低出生体质量患儿情况分析

目的了解重庆低出生体质量患儿情况并作5年动态比较。方法回顾性分析2005年1月至2009年9月重庆医科大学附属儿童医院新生儿诊疗中心收治的2 709例低出生体质量患儿的临床资料,应用SPSS 16.0软件进行统计学分析。结果①5年来,低出生体质量患儿在同期住院新生儿中的比例始终>11%。②住院新生儿中,不同出生体质量组的患儿其平均病死率比较,差异有统计学意义(χ2=50.070,P<0.05);出生体质量在1 500~2 000 g的患儿其病死率为正常出生体质量住院患儿的1.69倍,体质量<1 500 g的患儿病死率为正常出生体质量患儿的8.79倍。③男性患儿平均出生体质量较女性患儿重(t=2.247,P<0.05)。④重庆低出生体质量患儿以早产为主,平均占87.4%。⑤初产儿平均出生体质量较经产儿(产次≥2)高(F=15.146,P<0.05)。⑥低出生体质量患儿的母亲中,45.6%曾患各类感染性疾病。⑦近50.0%的孕母在生育旺盛期以外的年龄段进行生产,40.7%的母亲处于无业状态。结论尽可能防止早产,在可控范围内减少多胎妊娠并适度控制产次等方面是重庆市低出生体质量疾控工作的重要环节,加强对低出生体质量儿,尤其是极低出生体质量儿的监测护理,提高其存活率,是降低重庆市新生儿死亡率的关键。     

促红细胞生成素在超低出生体重儿的应用

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82例超低出生体质量儿的预后因素分析

目的总结超低出生体质量儿(extremely low birth weight infants,ELBWI)的一般资料,分析其影响预后因素。方法回顾性分析河南宏力医院2007—2014年收治的超低出生体质量儿的一般资料。结果 (1)一般资料:共收治82例,男39例,女43例,平均胎龄(27.5±1.8)周,平均出生体质量(836.5±100.7)g。孕母平均年龄(26.7±4.6)岁,经产妇39例,顺产60例,河南宏力医院出生46例,外院出生36例。产前应用激素37例,出生窒息42例。预后好转34例,放弃32例,死亡16例。(2)影响预后的因素分析:存活和死亡超低出生体质量儿胎龄、出生体质量以及河南宏力医院出生、产前激素、生后窒息率比较,差异有统计学意义(P<0.05)。胎龄及产前激素的应用与死亡负相关(胎龄:B=-0.214,P<0.05;产前激素:B=-0.737,P<0.05),生后窒息与死亡正相关(生后窒息:B=0.980,P<0.05)。结论避免小胎龄及生后窒息、产前应用糖皮质激素,可有效改善超低出生体质量儿的预后。