Improving health status in extremely low birthweight children between two and five years

The 5-year outcome of 101 extremely low birthweight (ELBW, < 1000 g) children discharged from the Neonatal Intensive Care Unit was reported. Over this period, there were four post-discharge deaths. The neurodevelopmental impairment rate was 18% overall: cerebral palsy 7%, blindness 3%, deafness 3% and developmental delay 10%. Seventy-one percent of children were readmitted to hospital. The mean number of admissions was 2.4 per child and the mean duration of total hospital stay was 11.3 days per child in the 5-year period. A trend was observed in a reduction in the readmission rate and hospital days in the 2–5-year period compared to the period between discharge and 2 years, though the differences were not statistically significant. The most common reason for readmission was for surgical procedures, primarily aural ventilation tube insertion and tonsillectomy and adenoidectomy. Significant health problems included recurrent wheezing episodes, stridor and croup in the period up to 2 years and otitis media and tonsillitis between 2 and 5 years. There was some catch-up growth, especially in height, between 2 and 5 years. Children with < 800 g birthweight had similar rates of neurodevelopmental impairment and hospital readmission to those of 800–999 g birthweight. However, they experienced more otitis media and pneumonia, had more ear, nose and throat operations, and at 5 years of age, more were below the 3rd centile for weight. This study showed that the health status of ELBW children had improved between 2 and 5 years, but they continued to experience recurrent health problems and hospital readmissions which would have resulted in added financial and emotional burdens to their families.     

Periventricular haemorrhage and leukomalacia in extremely low birthweight infants

Forty (49%) of 82 extremely low birthweight (ELBW, <1000 g) infants had periventricular haemorrhage (PVH). Ten (12%) had germinal layer haemorrhage (GLH) alone, 16 (20%) had intraventricular haemorrhage (IVH) and 14 (17%) had intracerebral haemorrhage (ICH). Almost all the cases of PVH had developed by 4 days of age. Small-for-gestational age infants (12% of study population) had a significantly lower incidence and severity of PVH than appropriate-for-gestational age infants. Of 94 infants born between 23 and 28 weeks gestation, 45 (48%) had PVH. The PVH incidence was 60% in those of 23-26 weeks and 38% in those of 27-28 weeks. The hospital survival rate of ELBW infants was 69% in those without PVH and 43% in those with PVH; 70% in GLH alone; 50% in IVH and 14% in ICH. Three survivors developed post-haemorrhage hydrocephalus of whom two required ventriculoperitoneal shunting. Five survivors developed periventricular leukomalacia (PVL) evidenced by cysts identified between 3 and 7 weeks of age. A significant decrease in the incidence of PVH occurred over the study period (67% in 1982, 38% in 1983 and 33% in 1984). This decrease was seen for ail grades of PVH. The reasons for this decreased incidence are still to be ascertained but this trend suggests that improvements in neonatal intensive care have the potential to improve the neurological outcome of more recent ELBW survivors.     

Examination of severe, hospital acquired infections affecting extremely low birthweight (ELBW) infants

PURPOSE: A nationwide questionnaire survey was carried out in 77 major neonatal intensive care unit (NICU) facilities in Japan. The survey investigated severe, hospital acquired infections occurring in extremely low birthweight (ELBW) infants at each institution. METHODS: The nationwide questionnaire survey involved 77 major NICU facilities and ELBW infants born in 1996. The actual status of severe infection in these infants was investigated. RESULTS: Replies were obtained from 57 of the 77 facilities that were sent a questionnaire (74% recovery). During the survey period, the total number of patients hospitalized in 57 facilities was 13697, of which there were 836 ELBW infants. During this period, severe infection occurred in 126 of the ELBW infants. Of those, 98 who developed delayed infection (72 h or more after birth) on the basis of the date of onset were investigated. Methicillin-resistant staphylococcus aureus (MRSA) was the most common organism found, (38 infants, 38.8%), followed by Pseudomonas (10 infants, 10.2%) and Candida (8 infants, 8.2%). Septicemia was present in 67 patients (68.4%), while pneumonia and gastrointestinal complications were found in 15 patients (15.3%). With respect to therapy, the selection of antibiotics varied between facilities. Vancomycin (VCM) was used in 31 cases (31.6%) because MRSA was the most common organism. VCM was used from the early stage of treatment in as many as 20 infants (20.4%). Fifty-eight infants survived (59.2%), 28 infants died (28.6%), and 12 subsequentially had obvious complications (12.2%). CONCLUSION: It was confirmed that severe, hospital acquired infections caused by MRSA are still a significant problem in many institutions. Despite active prevention and treatment, the incidence of severe, hospital acquired infection has not decreased and the prognosis has not improved. Considering the inadequacy of the medical care environment in Japan, it seems impossible to solve these problems at present.     

Estimated nutritional intake based on the reference growth curves for extremely low birthweight infants

BACKGROUND: Although the optimal goal of extremely low birthweight (ELBW) infants has been debated, it can be argued that the best nutritional strategy for ELBW infants is one which achieves better growth while preventing neurological sequelae due to nutritional inadequacy, even if it does not mimic fetal growth. Our aim is to propose an advisable and practically feasible nutritional intake for ELBW infants. METHODS: We retrospectively investigated the nutritional intake in 16 ELBW infants (gestational age 26.7 weeks, birthweight 879.6 g), who exceeded the standard growth curves for Japanese infants of ELBW. We also analyzed the nutritional composition of human milk from 15 mothers delivering before term (PT milk) until the 12th week of lactation. The nutritional intake was calculated according to the composition of the parenteral and enteral regimen. RESULTS: The infants tolerated more than 100 mL/kg per day of milk until the fourth week of life. An average weight gain of more than 15 g/kg per day was achieved by the sixth week. An advisable nutritional intake capable of sustaining ELBW infants in a stable growing phase was calculated as the sum of the mean plus 1SD of the daily nutritional intake. CONCLUSIONS: To exceed the ordinary growth curves for ELBW Japanese infants, it was suggested that more than 100 mL milk/kg per day could be fed until the fourth week of life, while the advisable daily intake of nutrients after six weeks of life should be as follows: water 160 mL/kg, protein 3.2 g/kg, fat 7.4 g/kg, carbohydrate 12.8 g/kg, energy 544 kJ/kg, the following minerals in mg/kg: sodium 45, chloride 82, potassium 110, calcium 140, phosphorus 70, magnesium 11, zinc 0.5 and copper at 60 micrograms/kg. Further studies will be needed to confirm the safety and effectiveness of this advisable intake for ELBW infants.     

Neurosensory outcome and growth at three years in extremely low birthweight infants: follow-up results from the Swedish national prospective study

A prospective national investigation comprising 633 extremely low birthweight (ELBW) infants born alive in the 2-y period 1990-1992 with a birthweight of ≤1000 g and gestational age of ≥23 completed weeks was conducted regarding neurosensory outcome and growth. Three-hundred and sixty-two (98%) surviving ELBW infants were assessed at a median age of 36 months, using a specially designed protocol. At follow-up, mean height, weight and head circumference in both boys and girls were significantly lower than the reference values. The incidence of cerebral palsy was 7% among all children and 14%, 10% and 3% in children born at 23-24, 25-26 and ≥27 gestational weeks, respectively. At least one obvious handicap was present in 14%, 9% and 3% of these three groups of children, respectively. After adjustment for gestational age, a significantly increased risk of handicap was found in children with intraventricular haemorrhage grade ≥3 and/or periventricular leucomalacia and in children with retinopathy of prematurity stage ≥3. The results show that more than 90% of ELBW children born at ≥25 completed gestational weeks were without neurosensory handicap at 36 months of corrected age. In infants born at 23-24 weeks of gestation, both survival and long-term outcome were less favourable.     

Extremely low birthweight infants at 3 years: A developmental profile

This study documents the neurodevelopmental outcome at 3 years of 52 of 55 extremely low birthweight (ELBW) survivors (survival rate 49%) born in a tertiary maternity centre from July 1985 through December 1988, and examines more closely the developmental profile of the neurologically normal survivors. At 3 years, 6 (12%) children had severe neurodevelopmental impairment (severe cerebral palsy, blindness, deafness or a General Quotient (GQ)<70 on the Griffiths Scales), 11 (21 %) had mild to moderate impairment and 35 (67%) had no neurosensory impairment and normal development (GQ≥ 85). Significant risk factors for severe impairment were stage 3 or 4 retinopathy of prematurity (odds ratio [OR] 21.5), treatment with postnatal steroids (OR 21), grade III or IV intraventricular haemorrhage (OR 11) and supplemental oxygen at 'term'(OR 6.4). The developmental profile of the 35 neurologically normal children revealed a significant weakness in eye and hand coordination skills and a relative strength in hearing and speech skills. Early recognition of this developmental profile may allow implementation of more appropriate preschool programmes for ELBW children.     

Erythromycin improves gastrointestinal motility in extremely low birthweight infants

Erythromycin (EM) was administered to five extremely low birthweight infants (ELBWI) with delayed enteral feeding to evaluate the clinical effect on severely impaired gastrointestinal motility. Five patients studied responded well to EM administration without any adverse effects during the course. Four patients were given 15–30 mg/kg per day EM intravenously as a loading and thereafter 3–5 mg/kg per day as a maintenance dose. One patient responded well without loading. The infants could be fed enterally 4, 5, 6, 4 and 2 days after the initiation of EM administration, respectively. Erythromycin administration is a safe and useful way to facilitate gastrointestinal motility in ELBWI who require prolonged ventilator support with an increased risk for nutrient deprivation.     

Predictive value of the Griffiths assessment in extremely low birthweight infants

Objective : To assess the relationship between the Griffiths Mental Development Scales at 1 and 3 years and the Stanford-Binet Intelligence Scale (S-B) and Beery Test of Visual-Motor Integration (VMI) at 5 years in extremely low birthweight (ELBW) children.
Methodology : Prospective study of 45 ELBW infants, without severe neurosensory impairment, cared for in a single Level III neonatal intensive care unit.
Results : At 5 years, 36 (80%) children were of average intelligence, 8 (18%) had borderline intelligence and one was mentally retarded. The Griffiths general quotient (GQ) at 1 year had a weak correlation with the S year IQ (corr. coeff. = 0.47), with only 17% of children with a GQ< — 1 s.d. at 1 year receiving an IQ< — 1s.d. at 5 years. In contrast, the Griffiths GQ at 3 years correlated strongly with 5 year IQ (corr. coeff. = 0.78). Among those children with a 3 year GQ< — 1s.d., 67% had a 5 year IQ< — 1 s.d. and all had a 5 year IQ<89. The 3 year hearing and speech subscale correlated strongly with the 5 year S-B verbal comprehension factor (corr. coeff = 0.753) and the 3 year combined eye/hand co-ordination/performance quotient had a moderate correlation with the S-B non-verbal reasoning factor (corr coeff = 0.597) and with the Beery VMI (corr coeff = 0.49).
Conclusions : The 3 year Griffiths GQ is a good predictor of 5 year S-B IQ in ELBW children and can be used to identify children who may benefit from intervention prior to school entry.     

Neonatal resuscitation of extremely low birthweight infants: a survey of practice in Italy

Delivery room management of extremely low birthweight infants (ELBWIs) has been little studied. A questionnaire was sent to the heads of the 86 Italian neonatal intensive care units provided with on site delivery. The practice of and approach to the resuscitation of ELBWIs were very different among the centres surveyed, reflecting a paucity of evidence and consequent uncertainty among clinicians.     

Longitudinal study of very low birthweight infants: Intelligence and aspects of school progress at 14 years of age

Abstract Consecutive surviving children weighing less than 1501 g when born in 1966–70 were followed prospectively: 87% (146/168) attended normal secondary schools, 4% (7/168) attended schools for those with special needs and 9% (15/168) were untraced. The psychologist assessed 140 children at a mean age of 14.5 years. The mean WISC-R Verbal Score of 89.7 was almost identical to that achieved by the children at 8 years of age (89.2). Thirty three children (24%) had delay in Reading Accuracy on the Neale Analysis of Reading Ability, whilst 66 children (48%) were delayed on the Comprehension Scale. Social class and duration of maternal education were significant predictors of the WISC-R Verbal Scores and Reading Comprehension at 14.5 years but the total variance explained was small. The Bayley Development Index (MDI) available for half of the children at 2 years often underestimated their potential as defined by the WISC-R Verbal Score at 14.5 years. The 8 year intelligence (WISC-R) and reading measures (Neale) were significantly and highly associated with the corresponding measures at 14.5 years. It was concluded that 8 years was an appropriate age to evaluate the outcome of the children and to identify many of those needing educational intervention. The spasmodic nature and sometimes short duration of the help received by many of the children underlines the need for more appropriate intervention for children with learning difficulties.     

Growth and catch-up growth of Australian infants of low birthweight

Abstract The growth of 90 infants of low birthweight (1500–2499 g) has been studied longitudinally from birth to 2 years of age. Seventy-five per cent of those infants were of birthweight that was appropriate-for-gestational age (AGA) and of mean gestational age 33.6 weeks (boys) and 34.5 weeks (girls). Twenty-four per cent were small-for-gestational age (SGA) and of mean gestational age 39.4 weeks (boys) and 38.5 weeks (girls). The data showed that, when gestational age was considered, the growth of AGA infants was similar to that of full-term infants of normal birthweight; SGA infants displayed accelerated growth ('catch-up'), particularly in the first months of life with upward percentile crossing from below the 5th toward the 50th. These results provide further evidence of the need to consider gestational age and whether AGA or SGA when assessing the growth of low birthweight infants.     

The Danish national study in infants with extremely low gestational age and birthweight (the ETFOL study): respiratory morbidity and outcome

AIM: To describe and analyse neonatal care, short and long-term morbidity with special reference to ventilatory support and chronic lung disease (CLD) in a population-based study. METHODS: During 1994 and 1995 a prospective, nation-wide, multicentre study was conducted, comprising 477 liveborn infants with gestational age (GA) < 28 wk and/or birthweight < 1000 g. Of these, 407 infants received active treatment. The ventilatory treatment was based on the principle of permissive hypercapnia and early nasal continuous positive airway pressure (NCPAP) supplemented with surfactant and ventilator therapy in case of CPAP failure. RESULTS: Among actively treated infants 85% received CPAP and 23% mechanical ventilation from the first day of life. A total of 269 infants (56%) survived to discharge. Of these, 195 had a GA < 28 wk. One-hundred and five survivors with GA < 28 wk survived with NCPAP as sole respiratory support. In surviving infants, periventricular leucomalacia/intraventricular haemorrhage grade 3-4 was found in 10%, retinopathy of prematurity grade > 2 in 4%, and oxygen requirement at 36 and 40 wk of postmenstrual age (CLD) in 16 and 5%, respectively. Three infants either died of CLD (n = 1) or required oxygen therapy beyond 43 wk of postmenstrual age. Logistic regression analysis showed significant associations between oxygen requirement at 40 wk and GA, septicaemia, mechanical ventilation, symptomatic patent ductus arteriosus and Clinical Risk Index for Babies score. Only the two last-mentioned factors proved significant in infants with GA < 28 wk. No infant died after discharge and 253 (94%) were followed up at 2 y of corrected age; one or more moderate to severe impairments were found in 66 (26%) of the examined children. CONCLUSION: Ventilatory treatment in extremely premature and extremely low-birthweight infants based on early NCPAP and permissive hypercapnia may result in comparable survival rates and sensorineural outcome; however, the incidence of CLD seems lower than that reported on conventional treatment.     

The long-term neurodevelopmental outcome for very low birthweight (VLBW) infants with 'dystonic' signs at 4 months of age

Abstract  As very low birthweight (VLBW) infants are at a high risk of developmental handicap, it is important to establish predictors of long-term adverse outcome at an early age so that early intervention can be instituted. Longitudinal neurodevelopmental assessments were performed in 107 VLBW infants at 1,4, 8 and 12 months corrected age. Eighteen were diagnosed as 'dystonic' at 4 months of age.
This study compared the outcomes at 4 and 6 years for 15 of the 18 dystonic with 75 of the 89 non-dystonic VLBW infants, respectively. At 9 years of age, nine dystonic and 54 non-dystonic infants were assessed on the Rutter Behaviour Questionnaire. Dystonic children had a lower mean General Cognitive Index (GCI; P= 0.001) and a higher incidence of disability as measured by the Burns Neuro-Sensori-Motor Developmental Assessment Scale (P = 0.0005) and Kitchen disability grading (P = 0.001). Even if the minor neurological aberrations of the premature dystonia syndrome in VLBW infants abate by one year of life, these infants still constitute a high-risk group for subsequent neurodevelopmental disability and therefore require close observation and probably early intervention.     

Rickets in extremely low birthweight infants

ABSTRACT. The effects of increasing the concentration of supplemental vitamin D was studied in two groups of ELBW infants (babies with a birth weight less than 1000 g) during the periods of July 1977 to December 1979 and throughout 1980. There were 21 ELBW infants in the first study period, with 7 infants developing active or Stage III rickets. A prospective study of ELBW infants during 1980 revealed 3 infants out of the 12 studied developing active or Stage III rickets. A new radiological classification for rickets of prematurity, Stage I to IV, is presented. Serial serum alkaline phosphatase levels were then compared with these radiological stages and a serial ALP of 500IU/l was found to be statistically significant in the biochemical diagnosis of rickets. As a result of our findings, we suggest that all ELBW should be supplemented with at least 800 IU of vitamin D daily.     

Choledocholithiasis in an infant of extremely low birthweight

A five-month-old infant of extremely low birthweight with choledocholithiasis is reported. A baby girl was delivered at 26 weeks gestation as a second twin, weighing 834 g. At 30 days of age, gallbladder stones were found by routine ultrasonography. She had vomiting at 157 days of age. Ultrasonography revealed calculi in the gallbladder and a dilated common bile duct. She was conservatively treated with scopolamine, antibiotics and dehydrocholic and ursodeoxycholic acids, and the calculi had disappeared by 189 days of age. Although conservative treatment succeeded in this patient, further cases should be analysed to establish how to manage choledocholithiasis in such small infants.     

Psychosocial and psychomotoric development of very low birthweight infants with necrotizing enterocolitis

Twenty-six very low birthweight infants (VLBI) were treated for necrotizing enterocolitis (NEC). We investigated their consecutive health problems and psychosocial development. Method: One to 13 years after onset of NEC, follow-up studies were performed in 12 of the surviving children. Identical follow-up studies were performed in 6 VLBI who had been operated on for diseases other than NEC (control group). We used a detailed interview, a Denver test and a drawing test. Results: Five children of the NEC group had major persistent health problems that impaired their psychomotoric and psychosocial development (including hearing impairment, concomitant strabismus, early onset bronchiai asthma). Nine of 12 VLBI of the NEC group showed signs of reduced social contact, logopaedic problems and minimal partial skill reductions. Conclusion: We found similar results in both children who suffered from NEC and in a small control group of VLBI who had not suffered from NEC, therefore impaired psychomotoric and psychosocial development is probably due to prematurity.     

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超低出生体重儿(extremely low birth weight infants,ELBWI)的救治是一个高风险的工作。在过去的20多年间,随着早产儿监护和治疗技术的不断提高,无论是发达国家还是发展中国家ELBWI的生存率都得到很大的提高。     

Selective improvement in cognitive test scores of extremely low birthweight infants aged between 2 and 5 years

Abstract The cognitive development at 2 and 5 years of a cohort of extremely low birthweight (ELBW) children (birthweight 500-999 g) was compared with that of cohorts of larger very low birthweight (VLBW) children (birthweight 1000-1500 g) and normal birthweight (NBW) children (birthweight > 2500 g) to determine whether the improvements in cognitive function of ELBW infants between 2 and 5 years are apparent or real.
At 2 years of age, ELBW children had a mean Mental Developmental Index (MDI) on the Bayley Scales of 90.4, significantly lower than the means of 100.3 for the larger VLBW children ( P = 0.006), and 107.8 for the NBW children ( P = 0.0002). However by 5 years the mean scores on the Wechsler Preschool and Primary Scales of Intelligence (WPPSI) full-scale for the ELBW and larger VLBW children were virtually identical (105.9 and 106.0 respectively)—but still lower than the mean WPPSI full-scale of 114.6 for the NBW children. After standardizing the MDI and WPPSI scores relative to the NBW children, the ELBW children improved between 2 and 5 years (paired t -test, t = 3.2, P = 0.004) whereas the larger VLBW infants did not.
We postulate that ELBW children require more time than larger VLBW children after birth to compensate for perinatal and other stresses, and that developmental delay at 2 years may not always persist to 5 years.