Antecedents of cerebral palsy in very low-birth weight infants

Research from the last two decades provides directions for efforts to prevent CP in VLBW infants. The pathogenesis of CP seems to involve factors operating both during pregnancy and in the neonatal period. The most important prenatal factor appears to be intrauterine infection. Perinatal infection and other risk factors, such as the death of a co-twin, placental abruption, and cerebral ischemia, could trigger a cytokine cascade resulting in damage to the developing brain. The low frequency of intrauterine infection in mothers with preeclampsia might explain the apparent protective effect of this disorder. If the brain damage attributed to intrauterine infection and other risk factors involves cytokines as intermediates, then blockade of the proinflammatory cascade or promotion of endogenous inhibitors might prevent CP. Other potentially preventive strategies include corticosteroids given to mothers (but not those given to neonates) and thyroid hormone.     

Outcome of very very low birth weight infants

This review of the literature and selected unpublished data documents normal early outcome in 50 to 81 per cent of tiny infants. Educational outcome described by a few studies is less encouraging, with only 32 to 36 per cent considered normal. Each study investigated the contribution of different perinatal, environmental, or social variables, therefore it is difficult to determine which has most impact on neurodevelopmental outcome.     

The survival of very low-birth weight infants by level of hospital of birth: a population study of perinatal systems in four states

This study estimates differentials in survival among very low-birth weight infants according to hospital of birth, and seeks to determine importance of birth at high-technology centers versus birth at other urban or rural hospitals. Data from four states for 1978 and 1979 were used to estimate survival curves for the first 24 hours of life by type of hospital at birth, birth weight, and race. Significant (p less than 0.0001) differences in survival by type of hospital for both races at birth weights of 1000 to 1500 gm were observed. Smaller disparities were seen at birth weights of 750 to 1000 gm. Differentials in survival by hospital setting emerged in the first few hours after birth, underscoring the effectiveness of neonatal intensive care units in reducing infant mortality and the importance of maternal transport. Differentials persisted throughout the neonatal and postneonatal periods, although differences were attenuated. Prenatal assessment and provider and institutional cooperation can contribute to lowered mortality for high-risk infants and mothers.     

Growth outcomes of very low-birth weight infants in the newborn intensive care unit

Advances in perinatal medicine will continue to improve our care and increase our understanding of the unique nutritional requirements of the VLBW infant and especially of the ELBW infant. Developments that permit neonatologists to meet those nutritional needs should improve the growth and well-being of VLBW infants. Longitudinal growth curves of hospitalized VLBW infants, such as the ones described in this article, should not be considered optimal and should be updated as ways safely to improve the growth of VLBW infants are identified.     

Outcome of very low birth weight infants with histopathologic chorioamnionitis

OBJECTIVE: To determine neonatal outcome at 7 months of corrected age in very low birth weight (VLBW) infants with placental chorioamnionitis. METHODS: We conducted a cohort study of 287 VLBW infants delivered as a result of preterm premature rupture of membranes (PROM) or preterm labor. Control subjects (n = 123) had placentas with absent umbilical cord inflammation and absent or low-grade membrane inflammation. Case subjects (n = 164) had moderate membrane inflammation or any umbilical cord inflammation. Neonatal and 7-month outcomes were compared. A power analysis showed that 98 total subjects were needed to reject the two-sided null hypothesis with a difference in mean Bayley index scores of at least 8. RESULTS: Infants in the study group had significantly more preterm PROM, antenatal antibiotics, lower birth weight, lower gestational age, longer duration of ruptured membranes, and clinical chorioamnionitis. Intraventricular hemorrhage occurred more commonly in infants with placentas demonstrating chorioamnionitis (relative risk = 1.6, 95% confidence interval 1.1, 2.4, P =.013). One hundred sixty-seven (69%) of the 243 surviving infants had 7-month follow-up. There was no difference between cases and controls in mean Bayley mental developmental index (93 compared with 90, P =.25), psychomotor developmental index (89 compared with 90, P =.68), or in the number of infants that were developmentally delayed. CONCLUSION: Despite a higher frequency of intraventricular hemorrhage, no difference in developmental scores was detected at 7 months of corrected age in VLBW infants with histologic chorioamnionitis.     

Ultrasonic estimation of weight in the very low-birth weight fetus: a resident versus staff physician comparison

The estimation of weight in the very low-birth weight fetus (less than 1500 gm) is becoming more important in obstetric management as neonatal nurseries are reporting better outcome in this weight category. It has become clear that assessment of weight can best be accomplished through the use of ultrasound. In many institutions, however, ultrasonography is under the control of other departments and is not readily available. This arrangement prevents rapid access and compromises the benefit of the technique. To evaluate the accuracy of scans performed in very low-birth weight infants by personnel with limited training in ultrasonography, we undertook a systematic study of weight estimates in this select group of patients. To date, 31 ultrasound examinations have been performed by staff physicians and 50 by resident physicians. Comparisons made between ultrasound examinations by staff and resident physicians showed that the absolute error between the ultrasound-predicted weight and the actual weight, though less in the case of staff physician examinations, was not statistically significant.     

Effect of early caffeine on neurodevelopmental outcome of very low-birth weight newborns

Objectives: The objective of this study is to evaluate the effect of early caffeine therapy started within the first 48?h of life on neurodevelopmental outcome in very low birth weight (VLBW) newborns.

Study design: VLBW newborns received either caffeine therapy within first 48?h of life (Early group), after 3rd day of life (Late group) or no caffeine during first month of life as per clinical team. A cohort of these newborns (n?=?160) who survived were evaluated using Bayley Scale of Infant Development III (BSID III) developmental testing between 18 and 22 months of corrected age.

Results: VLBW newborns in the “Early group” had significantly better composite, cognitive, language and motor BSID III scores as compared to those in “Late group” and no caffeine group. Composite BSID III scores were unchanged in the presence or absence of chorioamnionitis for “Early group”, while the BSID III scores were significantly lower in the presence of acute chorioamnionitis in “Late group” and no caffeine group.

Conclusions: Early caffeine therapy was associated with better BSID III scores in a cohort of VLBW newborns. Newborns with acute chorioamnionitis benefited from early caffeine therapy.     

Response of leukocytes and nucleated red blood cells in very low-birth weight preterm infants after exposure to intrauterine inflammation

Objectives.?To test the hypothesis if very immature preterm infants exposed to chorioamnionitis would exhibit increased numbers of leukocytes, neutrophils, and nucleated red blood cells (NRBC) in peripheral blood.

Study design.?Preterm infants with birth weight <1500?g were prospectively evaluated. Blood cells were counted within the first hour of life in infants exposed to histological chorioamnionitis and controls.

Results.?Birth weight, gestational age, and sex did not differ between the groups (n?=?71). Seventeen infants who were exposed to chorioamnionitis had significantly higher counts of leukocytes, neutrophils, and immature neutrophils after birth. However, there was no difference in the number of circulating NRBCs between both groups. In contrast, there was a tendency towards an increased NRBC count in the control group.

Conclusion.?Preterm infants exposed to chorioamnionitis elicited a strong inflammatory response as reflected by increased numbers of leukocytes and neutrophils. However, chorioamnionitis did not induce an increase in numbers of NRBC.     

Incisions of the pregnant uterus and delivery of low-birth weight infants

This paper calls attention to rapidly increased use of vertical uterine incision and future consequences: impaired uterus, uterine rupture, and iatrogenic premature delivery. In addition, by making a vertical uterine incision we are not gaining much in the size of uterine entrance since the size of the vertical uterine incision is determined by uterine tonus. Most often the uterus is opened by tearing the lower uterine segment transversely with the fingers. Unfortunately this creates the smallest entrance to the uterus because of the uterine structure, shape, and elasticity and could lead to parametrial vein and uterine vessel injury. An alternative to this type of incision is the durable upward curved transverse incision over the supportive lower uterine segment. This technique gives us the biggest entrance to the uterus, without serious side effects, and ensures safe future pregnancies.     

Outcome of very low birth weight infants exposed to antenatal indomethacin for tocolysis.

OBJECTIVE: Beginning in October 1995, and for several years thereafter, our institution used indomethacin as a first-line tocolytic drug. Our purpose is to compare the outcomes of very low birth weight infants who were exposed to antenatal indomethacin with those who were not exposed to this therapy. STUDY DESIGN: We used our center's component of the NICHD Neonatal Research Network's Generic Data Base which recorded the outcomes of all live born infants weighing less than 1500 g over a 5-year period. We abstracted data concerning neonatal morbidity (death, Grades III to IV intraventricular hemorrhage (IVH), necrotizing enterocolitis and patent ductus arteriosus), as well as other factors including gestational age, birth weight, antenatal corticosteroid treatment and maternal hypertension or pre-eclampsia. Univariate analysis was performed using Fisher's exact test. Multivariate analysis using logistic regression was performed to control for confounding factors. RESULTS: A total of 85 infants who were exposed to antenatal indomethacin were compared to 464 infants who were not exposed to the drug. In the univariate analysis, antenatal indomethacin exposure was not associated with a significant increase in the incidence of necrotizing enterocolitis or patent ductus arteriosus. The incidence of Grades III to IV IVH was 17.9% in those infants exposed to antenatal indomethacin compared to 7.1% in the nonexposed infants (p=0.008). The incidence of neonatal death in the exposed infants was 27.7 versus 16.4 in the nonexposed infants (p=0.02).After controlling for antenatal corticosteroids, maternal pre-eclampsia, gestational age and birth weight, antenatal indomethacin was significantly associated with an increased incidence of IVH, but not neonatal death. CONCLUSION: Antenatal indomethacin was associated with significantly higher rates of IVH. Additional studies assessing the potential risks of indomethacin tocolysis are needed before it is used as a first-line tocolytic therapy.     

Nutrition in very very low birth weight infants

The VVLBW infant's limited nutritional reserves, high requirements for normal growth and development, and gastrointestinal immaturity pose a particularly challenging nutritional problem. Given the potential consequences of inadequate or inappropriate nutritional management, we are obligated to make nutrition a high priority in the overall care of VVLBW infants.     

Nutrient composition of hindmilk produced by mothers of very low birth weight infants born at less than 28 weeks' gestation.

The objectives of this study were to describe and compare retinol, alpha-tocopherol and gamma-tocopherol, fat, energy, and nitrogen concentrations between the foremilk and hindmilk fractions of 24-hour milk collected by 24 mothers of very preterm (< 28 weeks' gestation) infants and to relate milk vitamins A and E content to maternal vitamin intake. Concentrations of retinol were significantly higher in hindmilk than in foremilk (1.6-fold), as were concentrations of alpha-tocopherol (1.6-fold), gamma-tocopherol (1.5-fold), fat (1.7-fold), energy (1.3-fold), and nitrogen (1.05-fold). Retinol, alpha-tocopherol, and gamma-tocopherol were positively related (P < .05) to milk fat and energy but not to maternal intake. Estimates of vitamins A and E intakes of infants fed hindmilk with added human milk fortifier surpassed current recommended upper level of intakes. The higher fat-soluble vitamin content of hindmilk produced by mothers of very low birth weight infants needs to be considered in the design and recommendations for use of human milk fortifier.     

A computer-based behavior monitoring system for low-birth weight infants under intensive care

For the intensive care of low-birth weight infants, it is important to continuously monitor behavioral changes. From this point of view, we have developed a computer-based monitoring system to analyze the body movements of low-birth weight infants under intensive care. The system consisted of a video recorder with a micro CCD camera for observing infant's body movements and a real time image processor for analyzing video frames. A 16 bit personal computer equipped with an image processor converted a video frame into a binary image that is a 256 by 256 matrix of pixels. The computer assessed each pixel of the matrix to determine whether the brightness changed between successive binary images or not. The number of changed pixels was counted every 1/30 sec, and such change reflected a infant's body movements. Using the system, body movements of a low-birth weight infant in an incubator were videotaped during 24 hours and analyzed. Results indicate that the behavior monitoring system developed in the present study has not only the ability to detect occurrences of movements of low-birth weight infants, but also the ability to qualitatively describe the pattern of movements.     

An advantage of isthmo-cervical longitudinal incision in cesarean section of low-birth weight infants

The pros and cons of the isthmo-cervical longitudinal incision of the uterus in order to deliver a very low birth weight infant are discussed. The advantages of the incomparably more careful taking out of the easily being injured fetus compensate disadvantages connected with this operative technique to a high degree.     

Neonatal survival and perinatal factors in infants born at 24 to 32 weeks of gestation

Clinical associations between neonatal survival and perinatal factors were studied in very premature infants delivered at Kurashiki Central Hospital Perinatal Center during April 1979 to March 1983. The very premature singleton infants without congenital anomaly were studied in the present work, including 45 live-birth infants born at 24 to 32 weeks of gestation and weighing 590 to 2,000g at birth. The mortality rate for male infants was higher than that for female infants, but this difference was not statistically significant. The mortality rate for infants born at 28 to 32 weeks of gestation was 2.9%, and that for infants weighing 1,000g or more at birth, respectively. The cause of all these neonatal death was massive aspiration syndrome with intracranial hemorrhage, and severe neonatal asphyxia. The mortality rate for infants born at 24 to 32 weeks of gestation was 60%, and that of infants weighing 999g or less, 60%, respectively. The cause of all these neonatal deaths was respiratory distress syndrome with intracranial hemorrhage. Clinically, it was suggested that cesarean section after onset of labor, PROM, and Betamethasone prior to delivery increased the survival rate of these infants statistically significantly. The most important neonatal complication in the prognosis of very premature infants was intracranial hemorrhage. The most correlated perinatal factors of neonatal intracranial hemorrhage were one min. Apgar score and fetal lung maturation.     

Family factors and social support in the developmental outcomes of very low-birth weight children

This study used data that were representative of the normative population of all infants born in 1988 and were followed during the first 3 years of life. Large developmental delays and limitations in function were common among children weighing less than 1500 g at birth. Among very low-birth weight infants, minority status and living in a household headed by a single mother further worsen the disadvantages associated with a very low birth weight. Nor could the disadvantages associated with very low birth weight be accounted for by controls for other risk factors or buffering statuses and behaviors. Among all children (including those of very low birth weight) poverty, reliance on Medicaid and other government sources for health insurance, a history of risky behaviors, and inadequate prenatal care are the major risk factors for developmental delays, limitations in function, and impairment at birth. State program benefit levels have no obvious effects on child outcomes, taking into account participation in individual programs. An important finding in light of TANF is that maternal work, the use of child care, and the form and cost of child care did not influence developmental delay, limitation in function, or impairment, the outcomes that we were able to measure during the first 3 years of life. TANF eligibility requirements, however, may increase difficulty in obtaining prenatal and other medical services for mothers and children in need--factors shown here to be related strongly to increased risk of low birth weight and developmental delays, limitations, and impairments. Race and ethnicity, poverty status, and family structure are fundamental factors in early child development and function. Minority status, poverty, and single-parent households greatly increase the likelihood that a mother will engage in risky behaviors (smoking, alcohol use, illegal drug use) during pregnancy and receive inadequate prenatal care. Risky behaviors and inadequate prenatal care are the major risk factors for a baby of very low birth weight. When perinatologists first encounter a new patient who is of very low birth weight they often see an infant who is minority, in poverty, and in a single-parent household. Although such children did more poorly in development and function by age 3, the major effects of these variables were through the selectivity of such children into very low birth weight; the direct impact of these factors on development is somewhat muted. This research suggests there are a number of policies that can reduce development delays and functional limitations among children in the United States. Programs that are targeted to a mother and child (such as WIC, AFDC, health insurance coverage, and possibly the more recent TANF programs) significantly reduced the risk an infant will be of very low birth weight. Access and use of adequate prenatal care are essential. Programs designed to combat maternal behaviors that place the fetus at risk (smoking, alcohol, and illegal drug use) can be very successful in reducing the likelihood an infant will be of very low birth weight. An additional payoff from such programs comes after the birth, because even taking into account birth weight, these variables negatively impact on early childhood development and function. Single-parent family structure, race and ethnic minority status, and poverty status also are known to impact on kindergarten readiness, so that we expect a delayed impact of these variables on the child. The strength of this article is the use of normative population data to assess the role of birth weight in child outcome. We examined prenatal risk factors for a baby of very low birth weight, traced the manner by which these selective risks are reflected in the composition of very low-birth weight babies, demonstrated how a very low birth weight was fundamental to delays in development, and identified risk factors and potential buffers in this process. (ABSTRACT TRUNCATED)     

Antecedents and outcome of very early neonatal seizures in infants born at or after term

Recent experimentally derived evidence has confirmed earlier suggestions that seizures which occur within 48 h of birth in babies born at or later than 37 completed weeks gestation are particularly likely to reflect intrapartum asphyxia. We have compared 54 cases of such seizures with 41,090 controls in a geographically defined population. Nulliparity, hydramnios, post-term pregnancy, oxytocin augmentation of labour, abnormalities of fetal heart rate and/or meconium-stained amniotic fluid, prolonged second stage of labour, emergency caesarean section, assisted vaginal delivery, low Apgar score and resuscitation at delivery and subsequent ventilatory support were all statistically significantly more common among cases than among controls. Five of the 54 babies who developed seizures died within 28 days of birth and 11 of the 49 survivors had an impairment diagnosed by 3 years of age which was usually associated with some degree of cerebral palsy. Comparison of the frequency of antecedent perinatal risk factors in the seizure babies who died, those who survived with disabilities and normal survivors failed to reveal any clear pattern.