Outcome of fetal echocardiography: A 17 year single‐institution experience in Japan

Background: The aim of this retrospective study was to evaluate the influence of prenatal diagnosis on perinatal outcomes of congenital heart disease (CHD) over a 17 year period at a single center. Methods: The perinatal outcome of CHD in 146 patients diagnosed on fetal echocardiography between 1994 and 2010 were reviewed. The characteristics of 193 neonatal inpatients with CHD treated at the authors’ department between 2001 and 2010 were also analyzed; among the inpatients, 61 were diagnosed before birth (prenatal group) and 132 were diagnosed after birth (postnatal group). Results: Among the 146 patients prenatally diagnosed with CHD, the prenatal mortality, including abortion and stillbirth, decreased from 1994 to 2010. Among the 193 neonatal inpatients, the prenatal group had lower gestational age and bodyweight than the postnatal group. Further, the prenatal group had lower blood pH at admission, but no patient in that group experienced ductal shock, although six patients in the postnatal group did. The average dose of prostaglandin E1 used in duct‐dependent CHD was significantly lower in the prenatal group than in the postnatal group (3.4 vs. 4.6 ng/kg per min; P = 0.015). Conclusions: Prenatal diagnosis of CHD enables planned labor, prevents ductal shock, and reduces prostaglandin E1 side‐effects and medical expenditure.     

Prenatal Diagnosis of Congenital Heart Disease and Birth Outcomes

This study was undertaken to examine the impact that prenatal diagnosis of congenital heart disease (CHD) has on birth and early neonatal outcomes. The prevalence of prenatally diagnosed CHD has risen over the past decade, but the effect that prenatal diagnosis of CHD has on peripartum decisions remains unclear. No consensus exists on the effect of prenatal diagnosis on neonatal outcomes. Between January 2004 and July 2009, a retrospective chart review of all neonates with CHD admitted to our institution’s neonatal intensive care unit was conducted. Obstetric and postnatal variables were collected. Among the 993 subjects, 678 (68.3 %) had a prenatal diagnosis. A prenatal diagnosis increased the odds of a scheduled delivery [odds ratio (OR) 4.1, 95 % confidence interval (CI) 3.0–5.6] and induction of labor (OR 11.5, 95 % CI 6.6–20.1). Prenatal diagnosis was not significantly associated with cesarean delivery when control was used for maternal age, multiple gestation, and presence of extracardiac anomaly. Mean gestational age had no impact on prenatal diagnosis, but prenatal diagnosis was associated with increased odds of delivery before a gestational age of 39 weeks (OR 1.5, 95 % CI 1.1–1.9) and decreased odds of preoperative intubation (OR 0.5, 95 % CI 0.3–0.6). Prenatal diagnosis did not have an impact on preoperative or predischarge mortality. Prenatal diagnosis was associated with increased odds of a scheduled delivery, birth before a gestational age of 39 weeks, and a decreased need for invasive respiratory support. Prenatal diagnosis of CHD was not associated with preoperative or predischarge mortality.     

Truncus Arteriosus: Diagnostic Accuracy,Outcomes, and Impact of Prenatal Diagnosis

Limited data exist on the impact of prenatal diagnosis and outcomes of fetal truncus arteriosus (TA). We sought to assess prenatal diagnostic accuracy and prenatal outcomes in fetuses with TA and compare postnatal outcomes in neonates with prenatally and postnatally diagnosed TA. Records were reviewed for patients diagnosed with TA in utero or at ≤60 days of life from 1992 to 2007. Forty-three (32%) of 136 TA patients had prenatal diagnosis. Five patients with TA were prenatally misdiagnosed, and 5 with other congenital heart diseases were misdiagnosed with TA prenatally. Of 28 fetuses diagnosed at <24 weeks gestation, 19 (68%) did not survive to birth because of spontaneous fetal death (n = 2) or because of elective termination (n = 17). Pregnancy termination was not more likely for fetuses with extracardiac anomalies. Of 19 live-born patients with correct prenatal diagnosis of TA, 2 (11%) died before surgery, and 4 (24%) died in the early postoperative period. All patients who died presurgically had been diagnosed prenatally. Overall, early postoperative mortality was 10%. Prenatal diagnosis of TA remains challenging and is associated with a high rate of elective termination. Fetal diagnosis was associated with younger age at repair but was not associated with improved neonatal survival.     

Risk stratification in gastroschisis: can prenatal evaluation or early postnatal factors predict outcome?

Purpose  The prenatal or postnatal factors that predict complex gastroschisis in patients (atresia, volvulus, necrotic bowel and bowel perforation) remain controversial. We evaluated the prognostic value of prenatal ultrasonographic parameters and early postnatal factors in predicting clinical outcomes. Methods  We analyzed maternal and neonatal records of 46 gastroschisis patients treated from 1998 to 2007. Information regarding demographics, prenatal ultrasound data when available, intrapartum and postnatal course was abstracted from medical records. Outcome variables included survival, ventilator days, TPN days, time to full enteral feeds, complications and length of stay. Univariate or multivariate analysis was used, with P < 0.05 considered as significant. Result  A total of 75% of complex patients were categorized within 1 week of life. Interestingly, prenatal bowel dilation (>17 mm) and thickness (>3 mm) did not correlate with outcome or risk stratification into simple versus complex (P < 0.05). Complex patients had increased morbidity compared to simple patients (sepsis 58 versus 18%; P = 0.021, NEC 42 versus 9%; P = 0.020, short bowel syndrome 58 versus 3%; P = 0.0001, ventilator days 24 versus 10; P = 0.021; TPN days 178 versus 38; P = 0.0001 and days to full feeds 171 versus 31; P = 0.0001; and length of stay 90 versus 39 days, P = 0.0001). Conclusions  Prenatal bowel wall dilation and/or thickness did not predict complex patients or adverse outcome. Complex gastroschisis patients can be identified postnatally and have substantial morbidity.     

The Impact of Prenatal Diagnosis of Complex Congenital Heart Disease on Neonatal Outcomes

Prenatal diagnosis of congenital heart disease (CHD) is increasingly common. However, the current impact of prenatal diagnosis on neonatal outcomes is unclear. Between January 2004 and January 2008, a retrospective chart review of infants who underwent surgical repair of CHD before discharge at our institution was conducted. Obstetric and perioperative variables were recorded. Of 439 neonates, 294 (67%) were diagnosed prenatally (PREdx). Infants with PREdx had a lower mean birth weight (3.0 ± 0.6 vs. 3.1 ± 0.6 kg, p = 0.002) and gestational age (37.9 ± 2.1 vs. 38.6 ± 2.4 wk, p < 0.001) than those with postnatal diagnosis (POSTdx). Severe lesions were more likely to be PREdx: Neonates with single-ventricle (SV) physiology (n = 130 patients [31.2%]) had increased odds of PREdx (n = 113/130, odds ratio [OR] 4.7; 95% confidence interval [CI] 2.7–8.2, p < 0.001). PREdx was associated with decreased preoperative intubation (OR 0.62; 95% CI 0.42–0.95, p = 0.033), administration of antibiotics (OR 0.23; 95% CI 0.15–0.36, p < 0.001), cardiac catheterization (OR 0.54; 95% CI 0.34–0.85, p = 0.01), and emergency surgery (OR 0.18; 95% CI 0.06–0.5, p < 0.001) compared with POSTdx infants. There was no difference in APGAR scores, preoperative pH, day of life of surgery, operative complications, hospital length of stay, or overall mortality in the PREdx versus POSTdx groups, even when controlling for lesion severity. PREdx was not independently associated with neonatal mortality, despite having included more severe cardiac lesions. PREdx was significantly associated with decreased neonatal morbidity in terms of decreased use of preoperative ventilator, administration of antibiotics, cardiac catheterization, and emergency surgery.     

Congenital duodenal obstruction: does prenatal diagnosis improve the outcome?

Prenatal diagnosis of congenital duodenal obstruction (CDO) provides information about associated anomalies; helps plan the delivery, resuscitation, and neonatal surgery; and allows for appropriate family counseling. This report compares the outcomes of two groups of newborns: one with prenatal diagnosis of CDO (group I) and the other without (group II). Charts of the 23 newborns with CDO admitted to the Hospital of UNICAMP between 1993 and 2001 were retrospectively reviewed. Ten (44%) newborns had prenatal diagnosis of CDO. Among group I patients, the postnatal diagnosis was confirmed on the 1st day of life, whereas patients without prenatal diagnosis (group II) had the diagnosis of CDO confirmed at a mean age of 5.7 days (p=0.004). The mean ages at surgery, at total oral feeding, and at hospital discharge were also statistically lower among infants with prenatal diagnosis, and more complications occurred in group II patients. The earlier care could explain the statistically lower morbidity for patients with prenatal diagnosis, since they were able to undergo further investigation and surgical repair before any impairment to their clinical status could take place. We believe that prenatal diagnosis of CDO, associated with earlier surgery and adequate postoperative support, can provide lower morbidity, decrease the hospitalization period, and, therefore, decrease its costs to the state and to society.     

Editorial: Money cannot buy happiness – but can it prevent depression? A commentary on Su et al.

In this issue, we read with interest Research Review: Developmental origins of depression – a systematic review and meta-analysis (Su et al., 2021). Su et al. (2021) conducted a systematic review and meta-analysis examining prenatal, perinatal and postnatal exposures and their association with depression in offspring. Su et al. (2021) evaluated twenty-eight potential exposures and determined that 12 were associated with increased risk of depression in the offspring. These risk factors included low birth weight, premature birth, being small gestational age, maternal education, socioeconomic status, parental age, parental smoking, maternal stress, maternal anxiety and prenatal depression (Su et al., 2021). Strikingly, each of these developmental risk factors for depression in the offspring is known to be associated with poverty.     

Chromosomal Anomalies Influence Parental Treatment Decisions in Relation to Prenatally Diagnosed Congenital Heart Disease

This study aimed to identify the variables that influence parental treatment decisions after a prenatal diagnosis of congenital heart disease (CHD). The authors reviewed all cases of prenatally diagnosed structural CHD from August 1998 to December 2006 at their center. The following variables were studied as potential predictors of parental intent to treat: maternal age, race, insurance status, obstetric history, fetal gender, univentricular versus biventricular cardiac physiology, and fetal chromosomal abnormality. Uni- and multivariable logistic regression analyses were performed. In the review, 252 consecutive cases of prenatally diagnosed CHD were identified. Of these, 204 women pursued full medical treatment, whereas 25 women sought termination of pregnancy or comfort care. Parental intent to treat was unknown for 23 cases. Multivariable logistic regression analysis identified fetal chromosomal abnormality as the only variable that influenced parental intent to treat (odds ratio [OR], 14.33; 95% confidence interval [CI], 3.28–62.66; p = 0.0006). An associated chromosomal abnormality rather than the severity of the heart defect influences the decision to choose termination of pregnancy or comfort care for a fetus with prenatally diagnosed CHD. Women were 14 times more likely to terminate a pregnancy or seek comfort care for a fetus with CHD if a chromosomal abnormality was present.     

Sensitivity,specificity, and accuracy of fetal echocardiography for high-risk pregnancies in a tertiary center in Egypt

BackgroundAdvances in fetal echocardiography training among pediatric cardiologists have led to substantial improvements in prenatal detection of congenital heart diseases (CHDs). Nevertheless, diagnostic accuracy varies among centers. Moreover, this subspecialty continues to evolve in developing countries, with limited studies assessing fetal echocardiography sensitivity, specificity, and accuracy in developing countries such as Egypt.Subject and methodsHigh-risk pregnancies referred for fetal echocardiography from January 2011 to January 2019 were analyzed retrospectively. All of the cases included had one of the high-risk indications for fetal echocardiography. Maternal age and gestational age at the prenatal diagnosis were determined, and detailed fetal and neonatal echocardiograms were documented. The results of fetal and postnatal echocardiography were compared to assess the sensitivity, specificity, and accuracy of fetal echocardiography. A minor lesion was defined when no postnatal intervention was needed and a major anomaly when postnatal cardiac therapy, surgery, or intervention was required.ResultsOut of 615 pregnant patients referred, comparisons between fetal and neonatal echocardiography were possible in 458 fetuses, with 157 patients excluded from the study. The mean maternal age in the study was 26.97 ± 5.871 years and the mean gestational age at referral was 27.24 ± 5.407 weeks. The most common indication for prenatal echocardiography in this cohort was a family history of CHD (142; 31%) followed by nonimmune hydrops (97; 21.18%) and abnormal obstetrical ultrasound screening (64; 13.97%). We had three false-positive minor diagnoses and four false-negative cases with only one requiring intervention. Prenatal diagnosis in this study was accurate in 98.47% of cases. The sensitivity, specificity, and accuracy of fetal echocardiography in the current work were 97.03%, 99.07%, and 98.47, respectively.ConclusionFetal echocardiography is considered a highly sensitive specific tool for prenatal detection of congenital heart diseases in high-risk pregnancies even in developing countries. However, minor fetal cardiac disorders are challenging to diagnose and family counseling should emphasize the difficulty of excluding or confirming such lesions.     

Efecto de la exposición prenatal y posnatal al tabaco en el desarrollo de bronquiolitis aguda durante los dos primeros años de vida

IntroductionEnvironmental exposure to tobacco increases the risk of respiratory disease in infants. However, the impact of maternal smoking on the development of acute bronchiolitis has hardly been assessed. The aim of this study was to determine the incidence of acute bronchiolitis and to analyse the effect of prenatal and postnatal maternal smoking on the development of this disease.Patients and methodsA prospective, observational study was performed on healthy newborns from a third level hospital born between October 2015 and February 2016. Questionnaires were completed by the mothers at discharge from maternity and followed-up for 2 years. These collected information about prenatal and postnatal smoking, lifestyle, family and personal history, and the development of bronchiolitis. A bivariate and multivariate logistic regression analysis was performed.ResultsA total of 223 newborns were included, of whom 13.9% were exposed to tobacco smoking during gestation, 21.4% in the postnatal period, and 12.4% in both times. The incidence of bronchiolitis was 28.7% at one year of life, and 34.5% at 2 years. The multivariate analysis demonstrated that the prenatal and postnatal exposure to tobacco is an independent risk factor for the development of bronchiolitis (OR 4.38; 95% CI: 1.63-11.76), while prolonged breastfeeding is a protective factor (OR 0.13; 95% CI: 0.04-0.48). Other factors that were statistically significant were: atopic dermatitis (OR 2.91; 95% CI: 1.26-6.73), and gestational age (OR 1.42; 95% CI: 1.08-1.88).ConclusionsChildren exposed to prenatal and postnatal maternal smoking have a higher risk of suffering bronchiolitis. Reducing the smoking habit in women that intend to become pregnant must be a priority in preventive medicine.     

Brain Maturity and Brain Injury in Newborns With Cyanotic Congenital Heart Disease

Patients with congenital heart disease (CHD) are at high risk for adverse neurodevelopmental outcomes. The aim of this work was to assess brain maturity and brain injury in newborns with cyanotic CHD using proton magnetic resonance spectroscopy (MRS). The study included 38 newborns with cyanotic CHD (study group) and 20 healthy full-term newborns (control group) matched together regarding gestational age and sex. Three-dimensional MRS showed that the mean ratio of N-acetylaspartate to choline (Ch) was significantly lower in newborns with cyanotic CHD (0.55 ± 0.08) compared with controls (0.67 ± 0.11) (p < 0.001). However, the mean ratio of lactate to Ch metabolite was significantly higher in the studied cases (0.14 ± 0.04) compared with controls (0.09 ± 0.04) (p < 0.001). The mean value for average diffusivity was 1.41 ± 0.06 in newborns with cyanotic CHD compared with 1.27 ± 0.07 in control newborns (p < 0.001), and the mean value for white-matter fractional anisotropy was 0.19 ± 0.03 in cyanotic newborns and 0.25 ± 0.08 in controls (p < 0.001). Newborns with cyanotic CHD are at increased risk of cerebral white matter injury as well as poor brain maturity. MRS provides a surrogate marker for early detection of such brain abnormalities.     

Accuracy of perinatal diagnosis of 45,X/46,XY mosaicism and electronic consultation of affected parents

ObjectiveTo assess parental satisfaction with e-mail consultations and fetal outcomes after consultation for offspring with 45,X/46,XY mosaicism.Patients and methodsA chart review was performed of prenatal and postnatal e-mail consultations concerning 45,X/46,XY mosaicism at our institution. Prenatally, mosaicism was detected by amniocentesis; postnatally by phenotype and subsequent genotyping. Parents e-mailed us for a second opinion after internet searches. Follow-up parental satisfaction was evaluated by e-mail.ResultsE-mail consultation occurred in six prenatal and eight postnatal cases. One of the eight postnatal cases had a prenatal diagnosis but without our second opinion. In 7/8 postnatal cases, abnormal neonatal phenotype was evaluated by genotyping. Termination of pregnancy was a consideration in all six prenatal consultations, although not discussed by us. One fetus was stillborn. Postnatal karyotype was mosaic in 11/13 surviving neonates. Phenotypes in surviving fetuses were normal male (2/13), hypospadias and an undescended testis or streak gonad (9/13), female with mild clitoral hypertrophy (1/13), and normal female (1/13). The stillborn fetus was noted only to have a penis.ConclusionAll parents reported in follow up that e-mail consultations provided them with enhanced clinical information, allowing them to make better informed clinical decisions.     

Congenital heart disease in a Chinese hospital: pre‐ and postnatal detection,incidence, clinical characteristics and outcomes

Background: The pre‐ and postnatal detection rate, incidence, clinical characteristics and outcomes of congenital heart disease (CHD) have been studied in developed countries for many years, but rarely have large‐scale studies been reported in Chinese populations. The aim of the present study was to investigate the pre‐ and postnatal detection rates, incidence, clinical characteristics and outcomes of CHD in a Chinese hospital in order to improve the future screening and treatment of CHD. Methods: Fetuses without risk factors for CHD were screened using basic cardiac ultrasound examination (BCUE). Fetuses with suspected cardiac malformation revealed by BCUE and fetuses with risk factors were screened using extended cardiac ultrasound examination. Outcomes recorded from fetal, neonatal and postmortem records over 4 years (2006–2009) included: therapeutic termination of pregnancy, spontaneous abortions or stillbirths, deaths at birth or in the neonatal period (before 28 days of age), and rate of birth and clinical characteristics of newborns. Results: A total of 34 071 fetuses were screened for CHD during a period of 4 years, of which 173 fetuses were screened for CHD using BCUE and 301 fetuses were screened using extended cardiac ultrasound examination. The incidence of fetal CHD increased from 1.1% in 2006 to 2.4% in 2009 (P < 0.05), yielding an overall incidence of 1.5% (523/34 071). Of the fetuses with CHD, 48.2% (252/523) died before 28 days of age (including intra‐uterine death and termination of pregnancy), 51.8% (271/523) lived more than 28 days and the incidence of live newborns with CHD was 0.80% (271/34071). Conclusions: The prevalence of CHD was quite common in this Chinese hospital. Detailed profiles of CHD suggest that, while training programs in obstetric screening at this hospital were beneficial, prenatal intervention, treatment and care of fetal CHD were inefficient and should be strengthened in China.     

MR imaging of fetal cerebral anomalies

Background. Prenatal diagnosis of fetal brain anomalies relies mainly upon ultrasonography. However, even in the most experienced hands, the technique has limitations for some difficult diagnoses. MRI is an excellent imaging modality for the paediatric and adult brain. Objective. To assess the value of prenatal MRI when a cerebral anomaly was detected by US and where the prognosis depended on the identification of other anomalies undetectable by US, or where fetuses were at risk for a CNS lesion even when the US was normal. Materials and methods. Four hundred prenatal MRI examinations were performed since 1988, and confirmed by postnatal follow-up or pathological examination. Two-thirds of the examinations were performed after 25 weeks of gestation, one-third between 21 and 26 weeks. Fetal immobilisation was obtained by maternal premedication with flunitrazepam, administered orally 1 h before the examination. The examinations were performed on 1.5 T scanners using one or two surface coils. Results. Prenatal MRI allowed the diagnosis of serious unsuspected lesions such as neuronal migration disorders, ischaemic and haemorrhagic lesions and the abnormalities observed in tuberous sclerosis. It helped to characterise ventricular dilatation and anomalies of the corpus callosum and of the posterior fossa. Conclusions. MRI is a valuable complementary tool when prenatal US is incomplete, doubtful or limited. Prenatal MRI is particularly useful for the detection of ischaemic and haemorrhagic lesions, neuronal migration disorders and tuberous sclerosis lesions. Detection of these associated anomalies worsens the fetal prognosis, has medico-legal implications and modifies obstetric management. Normal prenatal MRI does not exclude an anomaly. Received: 3 November 1997 Accepted: 7 November 1997     

Child maltreatment and foster care: unpacking the effects of prenatal and postnatal parental substance use

Parental substance use is a well-documented risk for children. However, little is known about specific effects of prenatal and postnatal substance use on child maltreatment and foster care placement transitions. In this study, the authors unpacked unique effects of (a) prenatal and postnatal parental alcohol and drug use and (b) maternal and paternal substance use as predictors of child maltreatment and foster care placement transitions in a sample of 117 maltreated foster care children. Models were tested with structural equation path modeling. Results indicated that prenatal maternal alcohol use predicted child maltreatment and that combined prenatal maternal alcohol and drug use predicted foster care placement transitions. Prenatal maternal alcohol and drug use also predicted postnatal paternal alcohol and drug use, which in turn predicted foster care placement transitions. Findings highlight the potential integrative role that maternal and paternal substance use has on the risk for child maltreatment and foster care placement transitions.     

Pitfall of newborn screening for congenital adrenal hyperplasia due to 21-hydroxylase deficiency

We report on a newborn with a severe salt-wasting crisis due to congenital adrenal hyperplasia (CAH) with 21-hydroxylase deficiency, in spite of prenatal diagnosis of CAH and awareness of this diagnosis by the parents and the gynecologic and pediatric practitioners. Due to the diagnosis of CAH in the older sister, prenatal treatment with dexamethasone (Dexa) was initiated. Prenatal diagnosis showed an affected male fetus and the prenatal treatment was stopped. The parents and the involved physicians were informed about the diagnosis, treatment, follow-up, and possible complications. Amniotic infection led to preterm delivery in another hospital. Due to perinatal asphyxia, the male newborn received Dexa during mechanical ventilation. Neonatal CAH screening was unsuspicious. An acute salt-wasting crisis with metabolic acidosis at the age of 3 weeks finally led to the correct diagnosis. This experience emphasizes the need to obtain a careful medical history. Furthermore, this case illustrates that neonatal screening for CAH is falsely negative in the event of neonatal Dexa treatment.     

新生儿先天性心脏病危险因素的病例对照研究

目的探讨新生儿先天性心脏病（简称＂先心病＂）的类型及其可能的危险因素,为制定预防措施提供参考依据。方法采用1∶1配对病例对照研究方法,选取2011年5月至2013年12月在本院新生儿科住院治疗的先心病患儿为病例组,无先心病的患儿为对照组,对两组患儿的亲生父母进行统一问卷调查。对所有研究因素进行单因素及多因素条件Logistic回归分析.筛选出与先心病发生相关的危险因素。结果研究期间本院新生儿科共收治3682例患儿,病例组和对照组各纳入139例。139例先心病患儿以室间隔缺损为主（34.5%）,其次为房间隔缺损＋室间隔缺损（14.4%）、房间隔缺损（10.8%）和室间隔缺损＋动脉导管未闭（10.1%）。母亲孕前及孕早期糖尿病（OR=7.321）、孕早期服用抗生素（OR=6.996）、孕早期被动吸烟（OR=4.948）、先心病家族史（OR=3.252）和孕早期上呼吸道感染（OR=3.461）均是先心病发生的相关危险因素（P〈0.05）。结论应加强孕期健康教育,提高产前产后诊断水平,以早期防治先心病,从而有效降低先心病的发病率。     

Gender specific differences in neurodevelopmental effects of prenatal exposure to very low-lead levels: The prospective cohort study in three-year olds

The primary purpose of this study was to assess the relationship between very low-level of prenatal lead exposure measured in the cord blood (< 5 µg/dL) and possible gender-specific cognitive deficits in the course of the first three years of life. The accumulated lead dose in infants over the pregnancy period was measured by the cord blood lead level (BLL) and cognitive deficits were assessed by the Bayley Mental Development Index (MDI). The study sample consisted of 457 children born to non-smoking women living in the inner city and the outlying residential areas of Krakow. The relationship between prenatal lead exposure and MDI scores measured at 12, 24 and 36 months of age and adjusted to a set of important covariates (gender of child, maternal education, parity, breastfeeding, prenatal and postnatal environmental tobacco smoke) was evaluated with linear multivariate regression, and the Generalized Estimating Equations (GEE) longitudinal panel model. The median of lead level in cord blood was 1.21 µg/dL with the range of values from 0.44 to 4.60 µg/dL. Neither prenatal BLL (dichotomized by median) nor other covariates affected MDI score at 12 months of age. Subsequent testing of children at 24 months of age showed a borderline significant inverse association of lead exposure and mental function (beta coefficient = − 2.42, 95%CI: − 4.90 to 0.03), but the interaction term (BLL × male gender) was not significant. At 36 months, prenatal lead exposure was inversely and significantly associated with cognitive function in boys (Spearman correlation coefficient = − 0.239, p = 0.0007) but not girls (r = − 0.058, p = 0.432) and the interaction between BLL and male gender was significant (beta coefficient = − 4.46; 95%CI: − 8.28 to − 0.63). Adjusted estimates of MDI deficit in boys at 36 months confirmed very strong negative impact of prenatal lead exposure (BLL > 1.67 µg/dL) compared with the lowest quartile of exposure (beta coefficient = − 6.2, p = 0.002), but the effect in girls was insignificant (beta coefficient = − 0.74, p = 0.720). The average deficit of cognitive function in the total sample over the first three years of life (GEE model) associated with higher prenatal lead exposure was also significant (beta coefficient = − 3.00; 95%CI: − 5.22 to − 0.70). Beside prenatal lead exposure, presence of older siblings at home and prenatal environmental tobacco smoke had a negative impact on MDI score. Better maternal education showed a strong beneficial effect on the cognitive development of children. Conclusion: the study suggests that there might be no threshold for lead toxicity in children and provides evidence that 3-year old boys are more susceptible than girls to prenatal very low lead exposure. The results of the study should persuade policy makers to consider gender-related susceptibility to lead and possibly to other toxic hazards in setting environmental protection guidelines. To determine whether the cognitive deficit documented in this study persists to older ages, the follow-up of the children over the next several years is to be carried out.     

Pulsoxymetriescreening kann die diagnostische Lücke bei kritischen angeborenen Herzfehlern verkleinern

Introduction

Neonates with critical congenital heart disease (cCHD) may be free of symptoms for a short period after birth, leading to a diagnostic gap. In some recent single-center studies, pulse oximetry screening (POS) has been proposed as an effective, noninvasive, inexpensive tool allowing earlier diagnosis of cCHD.

Aim of the study

To test the hypothesis that POS can reduce the diagnostic gap in cCHD in daily clinical routine in the setting of tertiary, secondary and primary care centers.

Methods

Prospective multicenter trial in Saxony, Germany. POS was performed in healthy term newborns at the age of 24–72 h. Newborns with a prenatal diagnosis or postnatal clinical signs of CHD were excluded. An oxygen saturation value (SpO2) ≥96% for the lower extremities was defined as normal. If a SpO2 of ≤95% was measured and confirmed after 1 h, a complete clinical examination and echocardiography were performed.

Results

From July 2006 until June 2007, 21,830 newborns from 31 institutions were included in the study. Thirty-three children were excluded due to prenatal diagnosis (n=22) or clinical signs of cCHD (n=11) before POS, and 506 newborns did not receive POS, mainly due to early discharge after birth (n=438, 87%). In 21,324 newborns, POS was performed. POS was true positive in 7, false positive in 18 (healthy n=6; neonatal sepsis n=2; PPHN n=10), true negative in 21,296, and false negative in 3 children. Sensitivity, specificity, positive and negative predictive value were 70%, 99.92%, 28.0%, and 99.99%, respectively.

Conclusion

POS can reduce the postnatal diagnostic gap in cCHD. It can also detect children with sepsis or PPHN. False positive results leading to unnecessary evaluation of healthy newborns are rare. Therefore, POS should be proposed as a routine procedure in postnatal care.     

Hypothalamic-pituitary-adrenal (HPA) axis function in 3-month old infants with prenatal selective serotonin reuptake inhibitor (SSRI) antidepressant exposure

Background

Prenatal exposure to stress and selective serotonin reuptake inhibitors (SSRIs) alter hypothalamic-pituitary-adrenal (HPA) stress reactivity in offspring, however, the effects of combined exposure to HPA activity in human infants is unknown.

Objective

To examine HPA basal levels and stress responsiveness in 3-month olds with prenatal exposure to SSRIs.

Methods

Salivary cortisol levels in infants of SSRI treated mothers (n = 31, mean exposure 230.2 ± 72.2 days) were compared with non-SSRI exposed (n = 45) infants in response to a challenge (infant-controlled habituation task) and under basal conditions in the late afternoon/early evening. Mode of feeding, to account for possible postnatal drug exposure via breast milk, as well as measures of pre and postnatal maternal mood, were included as covariates.

Results

Lower post-stress cortisol levels were observed in non-SSRI exposed/non-breastfed infants compared with non-SSRI exposed infants who were breastfed at 3 months of age. Stress reactivity patterns among SSRI exposed infants did not differ with mode of feeding. The cortisol reactivity slope (CRS) was significantly lower among non-SSRI exposed non-breastfed infants compared with non-SSRI exposed breastfed infants. Early evening basal cortisol levels were lower in SSRI exposed infants than in non-SSRI exposed infants, controlling for maternal mood and mode of feeding. Postnatal SSRI exposure (infant SSRI drug levels) via breast milk was not associated with stress or basal cortisol levels. Total cortisol, reflected by the AUC measure, did not differ significantly between exposure groups.

Conclusions

Prenatal SSRI exposure altered HPA stress response patterns and reduced early evening basal cortisol levels. Stress challenge HPA response differences only became apparent when the moderating effect of method of feeding was accounted for. These findings suggest an early “programming” effect of antenatal maternal mood, prenatal SSRI exposure and postnatal maternal care giving on the HPA system.