Patent ductus arteriosus complicating the respiratory distress syndrome in preterm infants.

In 46 preterm infants with RDS the patency of the ductus arteriosus was established by single film aortography or by clinical diagnosis and confirmation at surgery. The estimated left-to-right shunt through the PDA by aortogram correlated well with the heart size and the clinical diagnosis of heart failure. In 14 infants massive cardiomegaly and heart failure with a PDA occurred before the appearance of a heart murmur. Twelve infants had severe RDS and 34 had mild or moderate RDS. Massive cardiomegaly occurred significantly earlier in infants with severe RDS. It is suggested that ductal ligation is indicated when an infant with massive cardiomegaly requires IPPV and whose aortagram shows that all of the contrast material is in the pulmonary arteries and none in the aortic arch. A heart murmur may or may not be present.     

Development of chronic lung disease in preterm infants treated with surfactant

BACKGROUND: Chronic lung disease (CLD) is generally known to develop among preterm infants who have severe respiratory distress syndrome (RDS) at birth. Many clinical trials have established the efficacy of surfactant replacement therapy to treat RDS at birth with differing doses. In this study, the preterm infants diagnosed to have RDS at birth and treated with one or two doses of surfactant, depending on the severity of the RDS, were studied to evaluate the effect of surfactant on the later development of CLD. METHODS: A retrospective examination of case records of preterm infants who were born at < or = 28 weeks gestation period were studied. The subjects received a natural surfactant product (survanta) between September 1994 and April 1996 at the Monash Medical Center, Australia. RESULTS: Despite less severe initial lung disease, the subsequent respiratory outcome of infants who received one dose of surfactant, showed a trend towards being poorer compared to those who were diagnosed as having severe RDS at birth and received two doses of surfactant. At the corrected gestational age of 36 weeks, 54% of those infants began with mild RDS required oxygen, while only 44% of those who started with a severe RDS required supplemental O2. CONCLUSION: This study reports the infants with severe RDS at birth had responded slightly better or equally, compared to those with mild RDS, in terms of later development of CLD under surfactant treatment proportional to the severity.     

Early functional closure of the ductus arteriosus associated with decreased severity of respiratory distress syndrome in preterm infants

It has been shown that a patent ductus arteriosus may complicate the course of the respiratory distress syndrome (RDS) in preterm infants. In this study, an attempt is made to answer the question: Is there any relationship between RDS and patency of the ductus arteriosus in preterm infants, that is, do preterm infants without the RDS have early functional closure of the ductus arteriosus? Clinical observations were made on 144 preterm infants 25 to 34 weeks' gestation. Infants were included in the study if the status of the ductus arteriosus (open or closed) could be established either by clinical examination or retrograde aortography. The ductus arteriosus was closed in 59 infants within 48 hours of birth and open in 85. None of the infants with a closed ductus had severe RDS and only three had mild RDS. In contrast, 50% (43 of 85) of infants with open ductus had severe RDS. These findings suggest that early functional closure of the ductus can occur even in very immature infants, and this early closure appears to be associated with a decreased incidence of RDS.     

Early surfactant for neonates with mild to moderate respiratory distress syndrome: a multicenter, randomized trial

OBJECTIVE: We studied the efficacy and safety of electively providing surfactant to preterm infants with mild to moderate respiratory distress syndrome (RDS) not requiring mechanical ventilation. STUDY DESIGN: A 5-center, randomized clinical trial was performed on 132 infants with RDS, birth weight >or=1250 grams, gestational age or=40% for >or=1 hour, and no immediate need for intubation. Infants were randomly assigned to intubation, surfactant (Survanta, Ross Laboratories, Columbus, Ohio) administration, and expedited extubation (n=65) or expectant management (n=67) with subsequent intubation and surfactant treatment as clinically indicated. The primary outcome was duration of mechanical ventilation. RESULTS: Infants in the surfactant group had a median duration of mechanical ventilation of 2.2 hours compared with 0.0 hours for control infants, since only 29 of 67 control infants required mechanical ventilation (P=.001). Surfactant-treated infants were less likely to require subsequent mechanical ventilation for worsening respiratory disease (26% vs 43%, relative risk=0.60; 95% CI, 0.37, 0.99). There were no differences in secondary outcomes (duration of nasal continuous positive airway pressure, oxygen therapy, hospital stay, or adverse outcomes). CONCLUSIONS: Routine elective intubation for administration of surfactant to preterm infants >or=1250 grams with mild to moderate RDS is not recommended.     

Early-onset bacterial pneumonia: a comparison with severe hyaline membrane disease

ABSTRACT. The bacteriological and haematological features of 11 infants with early-onset bacterial pneumonia (EBP) were compared with those of 45 infants with severe hyaline membrane disease (HMD) to determine the sensitivity and predictive value of these features for the diagnosis of EBP in the presence of severe respiratory distress. All infants with EBP had positive surface site gram stains, abnormal total neutrophil counts, and increased immature: total neutrophil ratios but these features were also present in 18%, 40% and 22%, respectively, of infants with HMD. However, when these three features were combined all infants with EBP were identified (sensitivity = 100%) and all but one infant with HMD were excluded (predictive value = 92%).
The clinical and radiological features of EBP are nonspecific and all infants with respiratory distress should have surface site gram stains examined for bacteria. If these are positive, an abnormal total neutrophil count and an increased immature: total neutrophil ratio will distinguish EBP from HMD.     

Endogenous surfactant metabolism in newborn infants with and without respiratory failure

Studies using stable isotopically labeled glucose and palmitate as precursors of pulmonary surfactant synthesis have demonstrated slow surfactant turnover in premature infants with respiratory distress syndrome (RDS). However, only limited data about surfactant turnover are available for term infants. Because acetate is a direct precursor of de novo synthesized surfactant fatty acid, we measured [1-13C1]acetate incorporation into surfactant of term infants without respiratory dysfunction (control group), preterm infants with RDS, and term infants with primary respiratory failure to determine whether stable isotopically labeled acetate would yield similar results to previous studies of preterm infants with RDS and, furthermore, would distinguish normal from abnormal surfactant turnover. Despite similar amounts of phospholipids and acetate precursor enrichment, the control group had higher fractional synthetic rate and shorter half-life of clearance than preterm infants with RDS, (fractional synthetic rate, 15.4 +/- 2.4 versus 2.2 +/- 0.4%/d, p < 0.001; half-life of clearance, 27 +/- 3 versus 105 +/- 11 h, p < 0.001). Term infants with severe respiratory failure had a lower fractional synthetic rate than those with mild disease (2.9 +/- 0.6 versus 13.8 +/- 3.5%/d, p = 0.014) and a reduced amount of phospholipids recovered from tracheal aspirates (54 +/- 17 versus 300 +/- 28 nmol, severe versus mild disease, respectively, p < 0.001). The amount of phospholipids in tracheal aspirates correlated inversely with disease severity, (r = -0.75, p = 0.01). We conclude that normal surfactant turnover in term infants is faster than in preterm infants with RDS. Surfactant turnover in term infants with severe respiratory failure is similar to that of preterm infants with RDS, suggesting either delayed maturity of the surfactant system or disruption from the underlying disease process.     

Persistent pulmonary abnormalities in newborns: The changing picture of bronchopulmonary dysplasia

Significant changes in the radiographic features of bronchopulmonary dysplasia (BPD) have accompanied recent advances in treatment of neonatal respiratory distress syndrome. Retrospective study of 709 newborns showed atypical radiographic findings in many patients with clinical BPD. While 12/20 infants with clinical BPD showed changes identical to Northway's stage 4 disease, the remaining 8 (40% of patients with significant respiratory dysfunction) had diffuse, fine infiltrates without emphysema. Radiographic progression from RDS through all Northway stages was observed in only 4 patients. Diagnosis of stage 2 BPD was complicated by the presence of PDA in 9/17 cases. Stage 3 BPD was identified with certainty in only 5 infants, but may have coexisted with PIE in as many as 22 cases. Nevertheless, there was close agreement between the radiographic findings and clinical severity of chronic lung disease. Mild (type 1) infiltrates following RDS may be distinguished from chronic pulmonary insufficiency of prematurity (CPIP) or “immature lung”. In patients who require only short-term supplemental O₂, type 1 changes may reflect delayed resolution of RDS in an underdeveloped lung. These same findings in infants with prolonged O₂ dependence usually indicate a mild form of BPD. Coarse infiltrates and emphysema (type 2) are almost always associated with severe respiratory impairment.     

Diagnostic Performance of Point of Care Ultrasonography in Identifying the Etiology of Respiratory Distress in Neonates

Objectives

To determine the diagnostic test performance of Point of care ultrasonography (PoC-USG) for identifying the etiology of respiratory distress (RD) in neonates when combination of radiological and clinical criteria is considered as the gold standard.

Methods

A neonate was included in the study if he/she had RD and underwent x-ray chest and ultrasound within 4 h of admission and the age was less than 24 h. The neonates admitted with non-respiratory illness were chosen as controls. A trained neonatologist took trans-thoracic and trans-abdominal views and a radiologist, as per the defined criteria, did the interpretation.

Results

During the study period, 63 neonates with RD and 31 control neonates were enrolled. Overall from the clinical-radiological findings, the final diagnosis was respiratory distress syndrome (RDS), transient tachypnea of newborn (TTNB) and pneumonia in 29, 33 and one infants respectively. The ultrasound diagnosis of respiratory distress was RDS in 30 infants and TTNB in 33 infants. Pneumonia was not a diagnosis in any of the infants on PoC-USG. The sensitivity and specificity of USG in the diagnosis of respiratory distress were 98.4% and 100% respectively. One infant with diagnosis of pneumonia on chest x-ray was interpreted as RDS on USG.

Conclusions

PoC-USG can be used to diagnose different etiologies of RD in neonates.

     

Prediction of respiratory distress syndrome by the microbubble stability test on gastric aspirates in newborns of less than 32 weeks' gestation

AIM: There is a need for a rapid method to identify infants who will develop respiratory distress syndrome (RDS) soon after birth, to allow early treatment of affected infants with surfactant. The microbubble stability test (MST) may be one such method, but clinical experience is sparse. METHODS: The MST was performed on gastric aspirates from 188 infants with a mean gestational age of 29 (range 23-31) wk. RESULTS: 87 infants developed moderate to severe RDS, corresponding to a prevalence of 46%. The sensitivity, specificity and predictive values for identification of infants with moderate to severe RDS were determined for the average diameter of bubbles, the proportion of microbubbles with different diameters and the total number of microbubbles. The proportion of microbubbles with diameters <20 or 25 microm gave the best prediction, with a sensitivity of 78-79%, a specificity of 57-58%, a positive predictive value of 62% and a negative predictive value of 76%. Early treatment with nasal continuous positive airway pressure probably mitigated the development of RDS in some infants with a low-degree surfactant deficiency and this may explain the relatively low specificity. CONCLUSION: In infants of <32 wk gestation RDS can be predicted by computerized image analysis of the size distribution of microbubbles generated in gastric aspirates.     

Plasma guanosine 3',5'-cyclic monophosphate and severity of peri/intraventricular haemorrhage in the preterm newborn

A poorly controlled cerebral circulation, caused by excessive production of nitric oxide, has been suggested as predisposing to peri/intraventricular haemorrhage (PIVH) in the immature neonate. It is hypothesized that a relation exists between plasma cyclic GMP (cGMP) as an effector of endogenous vasodilatory nitric oxide production and severity of PIVH. In 83 consecutively admitted preterm neonates, nitric oxide production was assessed by measuring plasma cGMP at 0, 24, 48, 72 and 168 h of age. Simultaneously, cranial ultrasound investigations were performed and haemodynamic parameters registered. The investigations showed that 60 neonates (72%) had no PIVH; 18 neonates (22%) had mild to moderate PIVH; and 5 neonates (6%) had severe PIVH. At 48 and 72 h of age, cGMP levels of infants with severe PIVH were significantly higher than those of infants with no or only mild PIVH, whereas at 72 and at 168 h, infants with moderate PIVHs had significantly higher cyclic cGMP levels than infants without PIVH. Finally, at 168 h of age infants with mild PIVH also had higher cyclic cGMP values than those of infants without PIVH. Maximal cGMP values preceded the final extension of PIVH in moderate and severe PIVHs. Blood pressure support was necessary significantly more often in infants with moderate and severe PIVH. A logistic regression model revealed that cGMP was significantly associated with PIVH, irrespective of gestational age, mean arterial pressure or severity of infant respiratory distress syndrome. Conclusion: Increased cGMP levels are associated with the development of PIVH. It is suggested that vasodilatory nitric oxide-induced impairment of cerebral autoregulation plays a role here.     

Activation of the kallikrein-kinin system in premature infants with respiratory distress syndrome (RDS)

Plasma prekallikrein levels, kallikrein activity and antikallikrein levels were investigated in nine premature infants with respiratory distress syndrome (RDS) and six premature infants without. Plasma prekallikrein and kallikrein were determined with a chromogenic substrate measuring amidolytic activity. Antikallikrein was measured with a functional assay. In infants with severe RDS, prekallikrein levels were significantly reduced (median 58% of initial values (p less than 0.01) about 48 hours after onset of symptoms. In infants with moderate RDS prekallikrein level was reduced less, while in babies without RDS there were no significant changes in prekallikrein levels the first 5-7 days of life. Antikallikrein levels did not change significantly in any babies. The results suggest that the kallikrein-kinin system might be involved in RDS. This could explain several features of this syndrome such as hypotension and edema. Furthermore the findings show that homeostatic functions are altered in this disease, and they suggest that other cascade systems as the coagulation, fibrinolytic and complement system may be involved as well. The findings emphasize that trauma might be a significant pathogenetical factor for development of this syndrome and indicate that RDS is not simply a biochemical disease with lack of surfactant as the only pathogenetic factor.     

ACTIVATION OF THE KALLIKREIN-KININ SYSTEM IN PREMATURE INFANTS WITH RESPIRATORY DISTRESS SYNDROME (RDS)

ABSTRACT. Plasma prekallikrein levels, kallikrein activity and antikallikrein levels were investigated in nine premature infants with respiratory distress syndrome (RDS) and six premature infants without. Plasma prekallikrein and kallikrein were determined with a chromogenic substrate measuring amidolytic activity. Antikallikrein was measured with a functional assay. In infants with severe RDS, prekallikrein levels were significantly reduced (median 58% of initial values ( p <0.01) about 48 hours after onset of symptoms. In infants with moderate RDS prekallikrein level was reduced less, while in babies without RDS there were no significant changes in prekallikrein levels the first 5-7 days of life. Antikallikrein levels did not change significantly in any babies. The results suggest that the kallikrein-kinin system might be involved in RDS. This could explain several features of this syndrom such as hypotension and edema. Furthermore the findings show that homeostatic functions are altered in this disease, and they suggest that other cascade systems as the coagulation, fibrinolytic and complement system may be involved as well. The findings emphasize that trauma might be a significant pathogenetical factor for development of this syndrome and indicate that RDS is not simply a biochemical disease with lack of surfactant as the only pathogenetic factor.     

Description of the methodology used in an ongoing pediatric care interventional study of children born with cleft lip and palate in South America [NCT00097149]

Background

A number of infant pain measures have been developed over the past 15 years incorporating behavioural and physiologic indicators; however, no reliable or valid measure exists for infants who are at risk for neurological impairments (NI). The objective of this study was to establish consensus about which behavioural, physiologic and contextual indicators best characterize pain in infants at high, moderate and low levels of risk for NI.

Methods

A 39- item, self-administered electronic survey that included infant physiologic, behavioral and contextual pain indicators was used in a two round Delphi consensus exercise. Fourteen pediatric pain experts were polled individually and anonymously on the importance and usefulness of the pain indicators for the 3 differing levels of risk for NI.

Results

The strength of agreement between expert raters was moderate in Round 1 and fair in Round 2. In general, pain indicators with the highest concordance for all three groups were brow bulge, facial grimace, eye squeeze, and inconsolability. Increased heart rate from baseline in the moderate and severe groups demonstrated high concordance. In the severe risk group, fluctuations in heart rate and reduced oxygen saturation were also highly rated.

Conclusion

These data constitute the first step in contributing to the development and validation of a pain measure for infants at risk for NI. In future research, we will integrate these findings with the opinions of (a) health care providers about the importance and usefulness of infant pain indicators and (b) the pain responses of infants at mild, moderate and high risk for NI.     

Is nCPAP of value in extreme preterms with no access to neonatal intensive care?

This prospective study was undertaken to investigate the efficacy of nasal continuous positive airway pressure (nCPAP) in a group of extremely small infants denied access to a neonatal intensive care unit (NICU) in South Africa. Consecutive infants weighing less than 1200 g and/or of a gestational age below 28 weeks admitted to the neonatal ward with respiratory distress syndrome (RDS), and who were refused admission to the NICU, received either nCPAP (Infant Flow System E.M.E., UK) of headbox oxygen. Of 22 infants, 11 infants were included in the treatment group (nCPAP) and 10 in the control group. Within the first 24 h, two infants (18 per cent) in the nCPAP group and eight infants (80 per cent) in the control group died (p = 0.007) (survival OR = 18; RR = 4.09). A statistically significant improvement in the arterial-alveolar (a/A) oxygen ratio occurred in the nCPAP group between postnatal day 1 and day 3 of life (0.17 vs. 0.36; p < 0.005). Neonatal complications occurred in six (55 per cent) infants who survived the first 24 h of life. Eighty per cent of the infants with intraventricular haemorrhage (IVH) died, as well as all the infants who were born before arrival at the hospital. At the time of discharge from hospital, 45 per cent (five infants) in the nCPAP group survived vs. 20 per cent (two infants) in the control group. The neurodevelopmental outcome of six of the surviving seven infants were evaluated at 1 year of corrected age. The neurodevelopmental outcome as assessed by the Griffith Score was within normal limits in all infants. One infant has sensorineural deafness and one is deaf and has a possible mild spastic diplegia (both in the treatment group). We conclude that nCPAP significantly improves the short-term survival of very low birth-weight (VLBW) infants with moderate to severe respiratory distress syndrome who could not be admitted to intensive care. nCPAP significantly improves the a/A oxygen ratio between day 1 and day 3 of life.     

Pulmonary haemodynamics after surfactant replacement in severe neonatal respiratory distress syndrome.

Aortopulmonary pressure difference and pulmonary blood flow velocity were studied during the first 48 hours of life in 12 premature neonates with severe respiratory distress syndrome (RDS), treated by natural surfactant, and in 25 premature neonates with mild RDS. A non-invasive Doppler ultrasound method was used to estimate aortopulmonary pressure difference and pulmonary blood flow velocity from the left pulmonary artery. Aortopulmonary pressure difference was significantly lower at 6 hours of age in the infants with severe RDS and was not increased one hour after surfactant therapy. Aortopulmonary gradient started to rise at 24 hours of age and was equal to that of neonates with mild RDS at 48 hours. Pulmonary blood flow velocity was significantly lower, initially in the severe RDS group, and was not increased one hour after surfactant therapy. Left pulmonary artery flow velocity began to rise after 24 hours and reached the values of the mild RDS group at 48 hours. These data indicate that aortopulmonary pressure difference and pulmonary blood flow are low in the acute phase of RDS and that surfactant treatment does not seem to affect these values.     

Mothers' Representations of Their Infants Assessed Prenatally: Stability and Association with Infants' Attachment Classifications

The stability and predictive validity of Classifications of mothers' representations of their infants as determined by the Working Model of the Child Interview (WMCI) were examined. Concordance between mothers' representations of their infants assessed prenatally and again one year later and infant Strange Situation (SS) attachment classifications at 12 months was also examined. WMCI classifications were stable over 12 months in 80% of mothers, compared to 51 % expected by chance alone. Pregnancy WMCIs predicted infant SS classifications in 74% of cases, compared to 54% expected by chance. Concordance between 11-month WMCI and 12-month SS classifications was 73 % (vs. 55% expected by chance). Problems with the skewed distribution of the sample, the low concordance between pregnancy and 11 months for one of the three classifications, and future directions for research are discussed.     

心力衰竭婴儿血浆脑利钠肽水平变化的意义

目的探讨心力衰竭(HF)婴儿血浆脑利钠肽(BNP)水平变化与HF严重程度的关系,及其对婴儿HF诊断、心功能分级和疗效监测的临床意义。方法随机选取2006年10月-2008年9月在本院儿科住院的HF婴儿30例为研究对象,并根据Ross分级标准将其分成轻、中、重度3组。在HF纠正前后收集HF婴儿血浆,检测BNP水平。随机选取本院体检中心健康婴儿30例为健康对照组。健康对照组和HF组婴儿血浆BNP水平测定采用化学发光微粒子免疫分析法;采用M型超声心动图测量HF组婴儿的左心室射血分数(LVEF),并分析血浆BNP水平与LVEF的相关性。结果HF婴儿血浆BNP水平[(629.17±508.53)×10-6ng.L-1]显著高于健康对照组[(65.13±31.98)×10-6ng.L-1](t=4.884,P<0.05)。HF程度越重,血浆BNP水平升高越显著,血浆BNP水平与LVEF呈负相关(r=-0.508,P<0.05),与心功能分级呈正相关(r=0.527,P<0.01)。HF纠正后血浆BNP水平[(105.02±57.81)×10-6ng.L-1]显著低于HF纠正前[(629.17±508.53)×10-6ng...     

Influence of ethnic origin on respiratory distress syndrome in very premature infants

AIM—To determine whether the incidence of respiratory distress syndrome (RDS) is related to ethnic origin in very premature infants (?32 weeks of gestational age and birthweight ?2.0 kg).METHOD—A retrospective cohort study was performed to determine the incidence of respiratory disorders in African, Caribbean, and caucasian infants. An African infant was matched with two infants (one of Caribbean and one of caucasian descent) for gestational age and birth order and, if several eligible matching infants were found, for gender and approximate birth date. Fifty African infants (median gestational age 28 weeks, range 23-32) were matched with an infant of Caribbean and one of caucasian descent.RESULTS—Compared with the incidence of RDS in African infants (40%), that in caucasian infants (75%) was significantly higher (p<0.05), while the incidence in the Caribbean infants (54%) did not differ significantly. Regression analysis showed that ethnic origin was related to the occurrence of RDS independent of gestational age, size for dates, antenatal steroids, hypertension during pregnancy, premature rupture of membranes, maternal smoking, mode of delivery and infant gender.CONCLUSION—The enhanced lung maturation found in certain ethnic groups, even when born prematurely, has implications for clinical management.     

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目的了解儿童乙型肝炎病毒(HBV)基因型与临床分度的关系。方法选择甘肃省人民医院儿科和兰州大学第一医院感染科2008年4月至2010年4月门诊和住院患儿中HBV-DNA阳性的124例乙型肝炎患儿,其中男84例,女40例。HBV携带者65例,慢性乙型肝炎59例(轻度31例、中度18例、重度10例),对以上患儿进行基因分型、同时检测肝功、术前出凝血、HBV-DNA载量。结果 124例肝病患儿中,C基因型62例(50.0%),B基因型48例(38.7%),B/C混合型9例(7.3%),非B/C型5例(4.0%);HBV携带者和轻度组中,以B基因型为主,分别为47.7%和45.2%;中度和重度组中,以C基因型为主,分别为72.2%和80%;在C、B基因型分布方面,HBV携带者和轻度组与中度和重度组比较差异有统计学意义;C基因型患者的HBV-DNA载量、丙氨酸转氨酶(ALT)、天冬氨酸转移酶(AST)、总胆红素(TBIL)均高于B基因型;C基因型患者与B基因型比较,凝血酶原时间(PT)延长、凝血酶原活动度(PTA)下降、纤维蛋白原(FIB)减少。B、C型通过母婴传播的比例差异无统计学意义。结论甘肃省儿童乙型肝炎病毒基因...     

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.