极/超早产儿的生存现状和呼吸管理进展

极/超早产儿由于肺发育不成熟,病死率和支气管肺发育不良的发生率较高,呼吸管理和患儿的生存率及生存质量密切相关.合理的产前皮质激素促肺成熟、肺表面活性物质(pulmonary surfactant,PS)的应用和机械通气策略有助于改善极/超早产儿的预后.采用无创技术进行呼吸支持,特别是生后立即给予持续气道正压通气而后根据病情选择性给予PS作为预防性给予PS的替代呼吸支持策略已受到普遍推荐.新的机械通气策略与模式如高频振荡通气、神经调节辅助呼吸和目标容量通气是否具有更大的优势仍需要进一步的研究证实.     

Prediction of outcome at 5 years from assessments at 2 years among extremely preterm children: a Norwegian national cohort study

Aim: To examine the predictive value of early assessments on developmental outcome at 5 years in children born extremely preterm. Methods: This is a prospective observational study of all infants born in Norway in 1999–2000 with gestational age (GA) <28 weeks or birth weight (BW) <1000 g. At 2 years of age, paediatricians assessed mental and motor development from milestones. At 5 years, parents completed questionnaires on development and professional support before cognitive function was assessed with Wechsler Preschool and Primary Scale of Intelligence‐Revised (WPPSI‐R) and motor function with the Movement Assessment Battery for children (ABC test). Results: Twenty‐six of 373 (7%) children had cerebral palsy at 2 and 29 of 306 (9%) children at 5 years. Of children without major impairments, 51% (95% CI 35–67) of those with and 22% (95% CI 16–28) without mental delay at 2 years had IQ <85 at 5 years, and 36% (95% CI 20–53 with and 16% (95% CI 11–21) without motor delay at 2 years had an ABC score >95th percentile (poor function). Approximately half of those without major impairments but IQ <85 or ABC score >95th percentile had received support or follow‐up beyond routine primary care. Conclusion: Previous assessments had limited value in predicting cognitive and motor function at 5 years in these extremely preterm children without major impairments.     

Outcome of extremely low-birth-weight infants: 1980–1990

Neonatal and follow-up data of infants from the special care nursery whose birth weights were < 750 g, born between 1980 and 1990, were reviewed. There was a 20% relative improvement in the odds of surviving the neonatal period, a 16% improvement in the odds of being discharged and a 19% improvement in the odds of surviving until 2 years of age with each consecutive year. Home oxygen use increased significantly over the study period. The neurodevelopmental outcomes of infants were similar over the 11-year period, with 53% being classified as neurologically normal, with a mean developmental index of 83 at 1 to 2 years of age. We conclude that there has been an improved survival of infants with birth weights < 750 g in our institution, and that the overall incidence of serious neurodevelopmental deficits among survivors has remained stable.     

Neurodevelopmental outcome at 12 and 18 months in late preterm infants

BackgroundLate-preterms represent the 70% of the whole preterm population and are reported to be at higher risk for mortality and morbidity than term infants.AimsTo assess neurodevelopmental outcome in low-risk late-preterm infants at 12 and 18 months corrected age, to compare results of corrected and uncorrected age to those of term-born infants, to analyse the possible influence of gender on outcome.MethodsSixty-one healthy infants born between 33 and 36 weeks gestational age without major brain lesions were assessed at 12 and 18 months corrected age using the Bayley II scale. A control group of 60 low-risk term born infants underwent the same assessment.ResultsAt 12 and 18 months corrected age late preterms showed a mean mental developmental index (MDI) similar to term infants. Comparing the results of the uncorrected age with term infants, the scores were significantly lower at both 12 and 18 months. No gender differences were observed in term-born infants, while male late-preterm infants showed lower MDI than peer females at both ages.ConclusionsWhen correcting age for prematurity late-preterms have similar MDI scores to those obtained in term-born infants at 12 and 18 months. In contrast, when using chronological age there is a number of infants with low MDI. As cognitive abnormalities are reported at school age in late preterm infants, our findings raise the question on whether the results obtained using scores uncorrected for age may early identify the infants who will show cognitive difficulties at school age.     

Adverse neurodevelopmental outcome in preterm infants: risk factor profiles for different gestational ages

Aim: Assessment of risk predictors for adverse neurodevelopmental outcome at 1 year of age in preterm infants with a gestational age <30 weeks (Group I) and 30–32 weeks (Group II).
Methods: Between January 2003 and December 2006, we prospectively enrolled 310 live-born infants between 23 and 32 weeks of gestation. The association between candidate risk factors and delayed motor or mental development (Bayley Scales of infant development II; psychomotor or mental developmental index <85) was analysed by means of logistic regression analysis.
Results: Two hundred and fifty infants were eligible for follow-up, and 205 (82.0%) completed the follow-up visit. Intracerebral haemorrhage, small for gestational age and late-onset sepsis were associated with an increased risk for delayed development in Group I (p < 0.05, each). Premature rupture of membranes was a risk condition relevant to Group II. Antenatal steroids were associated with a decreased risk of neurodevelopmental delay in both groups.
Conclusion: This study identified distinct risk factors for adverse outcome in preterm infants of lower (<30 weeks) and higher (30–32 weeks) gestational age. In the lower gestational age group, neonatal risk predictors are most important. Antenatal steroids appear to decrease the risk for adverse outcome in both age groups.     

超未成熟儿的生存状况与预后影响因素分析

目的 探讨胎龄28 周以下超未成熟儿在新生儿重症监护病房（NICU）的存活率、住院期间并发症发生情况及其预后。方法 收集2011 年1 月至2013 年3 月入住NICU 的胎龄结果 90 例患儿平均胎龄26±1 周,出生体重898±165 g,总存活率为57%,病死率9%,放弃率34%。常见并发症包括新生儿呼吸窘迫综合征（RDS）88%、BPD 85%、PDA 69%, ROP 68%,Ⅲ、Ⅳ级IVH 31%;存活早产儿平均住院时间为83±18 d,出院平均体重为2419±300 g。多因素logistic 回归分析发现,肺出血与严重IVH 为死亡或放弃的高危因素,产前使用糖皮质激素为保护因素。结论 目前国内超未成熟儿存活率相比发达国家仍有较大差距;肺出血、严重IVH 为影响预后的重要因素。     

Compared outcomes of very preterm infants born in 2000 and 2005

AIM: To compare neonatal and 2-year outcomes in very premature infants born 5 years apart. METHODS: Prospective observational study of infants born before 33 weeks' gestation in 2000 or 2005 admitted to a neonatal intensive care unit in France. We collected perinatal data and evaluated motor, cognitive, neurosensory and behavioural outcomes at 2 years of age. Results: We included 170 infants in 2000 and 173 in 2005. The significant differences in neonatal outcomes were decreases in postnatal corticosteroid use and in percentage of infants with head circumference below the 3rd percentile on days 7 (25% vs. 13%) and 30 (30% vs. 17%). At 2 years of age, rates of follow-up were 87% in 2000 and 94% in 2005. The cerebral palsy rate was 6% in both cohorts. The overall rate of motor disabilities diminished from 30% (41/137) to 18% (26/142), and the rate of mild motor disabilities decreased from 24% to 12%. Rates of cognitive, behavioural and neurosensorial impairments were similar. Conclusion: Between 2000 and 2005, motor impairments at 2 years of age diminished in very preterm children (but not cerebral palsy rates). We observed a reduced use of postnatal corticosteroids and a decreased percentage of neonates with head circumference below the third percentile.     

Influence of clinical status on the association between plasma total and unbound bilirubin and death or adverse neurodevelopmental outcomes in extremely low birth weight infants

Objectives: To assess the influence of clinical status on the association between total plasma bilirubin and unbound bilirubin on death or adverse neurodevelopmental outcomes at 18–22 months corrected age in extremely low birth weight infants. Method: Total plasma bilirubin and unbound bilirubin were measured in 1101 extremely low birth weight infants at 5 ± 1 days of age. Clinical criteria were used to classify infants as clinically stable or unstable. Survivors were examined at 18–22 months corrected age by certified examiners. Outcome variables were death or neurodevelopmental impairment, death or cerebral palsy, death or hearing loss, and death prior to follow‐up. For all outcomes, the interaction between bilirubin variables and clinical status was assessed in logistic regression analyses adjusted for multiple risk factors. Results: Regardless of clinical status, an increasing level of unbound bilirubin was associated with higher rates of death or neurodevelopmental impairment, death or cerebral palsy, death or hearing loss and death before follow‐up. Total plasma bilirubin values were directly associated with death or neurodevelopmental impairment, death or cerebral palsy, death or hearing loss, and death before follow‐up in unstable infants, but not in stable infants. An inverse association between total plasma bilirubin and death or cerebral palsy was found in stable infants. Conclusions: In extremely low birth weight infants, clinical status at 5 days of age affects the association between total plasma bilirubin and death or adverse neurodevelopmental outcomes at 18–22 months of corrected age. An increasing level of UB is associated a higher risk of death or adverse neurodevelopmental outcomes regardless of clinical status. Increasing levels of total plasma bilirubin are directly associated with increasing risk of death or adverse neurodevelopmental outcomes in unstable, but not in stable infants.     

Improved outcome for infants at the limits of viability

Factors associated with survival and freedom from cerebral parenchymal lesions and severe retinopathy were examined in a cohort of 250 extremely preterm infants of less than 26 weeks gestation admitted to a regional neonatal intensive care unit between 1982 and 1993. There were 99 survivors of whom 73 were free of major early morbidity.     

Long-term neurodevelopmental outcome of preterm children with unilateral cerebral lesions diagnosed by neonatal ultrasound

OBJECTIVE: Little information is available on long-term neurodevelopmental outcome of preterm infants with unilateral cerebral lesions detected by neonatal cranial ultrasound. This study aims to investigate the long-term outcome in a cohort of very preterm infants with unilateral cerebral lesions acquired in the perinatal period. METHODS: A prospective cohort study of 668 preterm infants (<33 weeks gestation; birth years 1985-1991) at a single tertiary perinatal centre in the UK. All infants had serial cranial ultrasound examination in the neonatal period. Outcome was assessed at age 8 years with the Wechsler Intelligence Scales for Children (WISC-R), Test of Visuo-motor Integration (VMI) and the Test of Motor Impairment (TOMI). RESULTS: Of the 668 infants, 369 infants had normal ultrasound scans. Two hundred and ninety nine children had bilateral parenchymal or non-parenchymal lesions (57 left-sided, 41 right-sided, 201 bilateral). Five hundred and thirty four (79%) children attended follow-up at age 8 years. Mean Full Scale IQ (FSIQ) was 101 (SD+/-16), 93 (SD+/-17), 102 (SD+/-17) and 91 (SD+/-21) for normal, left-sided, right-sided and bilateral lesion groups respectively. In all groups verbal IQ (VIQ) was higher than performance IQ (PIQ). Scores of FSIQ, VIQ and PIQ, VMI and TOMI were significantly different between the groups. After exclusion of children with parenchymal lesions, however, the difference was only significant for the TOMI scores. In all tests, children with left-sided lesions performed poorer than children with right-sided lesions. CONCLUSIONS: In this cohort of preterm infants with unilateral cerebral lesions, verbal function was preserved over non-verbal function independently of the side of lesion. Furthermore, the results suggest that the neurodevelopmental outcome of children with left-sided lesions is less favourable than that of children with right-sided lesions.     

Short-term outcome in infants with a birthweight less than 501 grams

AIM: To report survival and morbidity until discharge in preterm infants <501 g with life support started immediately after birth. Methods/study design: Cohort study of all preterm infants with birthweights < 501 g born in three tertiary perinatal centres between 1 January 1998 and 31 December 2001 (gestational age (GA) 25.2 [21.0-30.7] wk; birthweight 435 [290-500] g; median [range]). RESULTS: A total of 107 infants with birthweights <501 g were born. Twenty-nine were stillborn. A prenatal decision to initiate life support immediately after birth was reached in 9/37 (24%) infants <24.0 wk GA and in 39/42 (93%) infants > or =24.0 wk GA. Survival was 3/37 (8%) and 26/41 (63%) in infants <24 wk GA and > or =24.0 wk GA, respectively. Twenty-nine of the 48 infants with immediate life support (60%) survived (95% CI: 46-75%). Forty-two of these 48 (88%) infants were small for gestational age. No infant without immediate life support survived (0/30). Twenty-three (79%) survivors developed chronic lung disease (CLD) and eight (28%) received photocoagulation for retinopathy of prematurity (ROP). CONCLUSION: In this population of extremely low birthweight infants, survival was higher than in previous studies when life support was provided immediately after birth. Short-term morbidity was similar to other studies. The presented data on survival support our concept to offer immediate life support after birth in preterm infants with birthweights <501 g. The long-term outcome of these infants needs to be assessed urgently.