高危晚期早产儿脑损伤病因学及其磁共振发现

目的 探讨以弥散加权成像(DWI)结合常规磁共振成像(T1WI-T2WI)诊断的高危晚期早产儿脑损伤的相关危险因素及临床特点,并分析不同时间MRI序列的信号特点及DWI的早期诊断价值。方法 首先对符合纳入标准的649例晚期早产儿的MRI片重新阅片,按照脑损伤评估标准得出诊断,其次收集相关的临床资料,分析不同类型脑损伤的危险因素和临床特点,并对其中271例确诊脑白质损伤（CWMD）的MRI序列进行分析,探讨不同类型CWMD的信号特点、损伤部位及结局。结果 ①晚期早产儿发生脑损伤332例（51.2%）,其中CWMD 271例（41.8%）,以局灶性CWMD为主（62.7％,170例）;颅内出血112例（17.3%）,主要为蛛网膜下腔出血55.4%（62/112）。②非出血性脑损伤的危险因素是男性（OR=1.510,95％CI：1.067～2.136,P=0.020）、阴道分娩（OR=2.367,95％CI：0.251～22.294 ,P=0.000）、早发型败血症（OR=2.194,95％CI：1.159～4.155,P=0.016）及抢救复苏史（OR=3.784,95％CI：1.908～7.506,P=0.000）。出血性脑损伤的危险因素是阴道分娩（OR=7.195,95％CI：4.249～12.184 ,P=0.000）和早发型败血症（OR=2.692,95％CI：1.185～6.117,P=0.018）。低钙血症（OR=2.593,95％CI：1.343～5.005,P=0.005）、晚发型败血症（OR=1.533,95％CI：1.012～2.323,P=0.044）和抽搐（OR=4.006,95％CI：1.790～8.970,P=0.001）是非出血性脑损伤组的主要临床特点。出血性脑损伤组主要表现为高血糖和抽搐。③局灶性CWMD 65.3％仅累及一处损伤,主要集中在侧脑室后脚（53.5%）,有97.1%病灶消失或病灶范围减少;广泛性CWMD 79.2%累及胼胝体和内囊;弥漫性CWMD 50％合并灰质损伤,全部发生软化。④生后2周内,DWI具有较高的敏感性,98.0%表现为高信号,T1WI信号无变化或稍高信号,伴或不伴T2WI低信号。局灶性CWMD DWI高信号持续时间长达3周以上,弥漫性CWMD DWI高信号持续时间2周以内。结论 晚期早产儿仍然容易受产前产时因素影响而发生不同类型的脑损伤。对有高危因素,或早期出现临床表现或电解质紊乱的患儿应选择生后2周内（1周内最佳）进行DWI和常规MRI检查,以早期发现病变。局灶性CWMD预后较好,合并有灰质损伤或弥漫性CWMD预后极差,需要动态随访,并进行早期康复训练。     

Maternal and paternal recreational drug use and sudden infant death syndrome.

OBJECTIVE: To determine whether maternal or paternal use of cocaine, opiates, or marijuana during conception and pregnancy and postnatally increases the risk of sudden infant death syndrome (SIDS) during the first year of the infant's life. This is an important issue and may prove useful in further decreasing the rate of SIDS. METHODS: A case-control study was conducted consisting of 239 infants who died of SIDS in southern California between 1989 and 1992, and 239 healthy infants who were matched on the basis of birth hospital, date of birth, age, and sex. Specific drug use at the period of conception, during pregnancy and breastfeeding, and in the presence or vicinity of the infant was ascertained by telephone for the white, African American, Hispanic, Asian American, and Pacific Islander case and control fathers and mothers. RESULTS: Maternal recreational drug use during pregnancy was not associated with the risk of SIDS after adjusting for maternal smoking during pregnancy (adjusted odds ratio [OR] = 2.0; 95% confidence interval [CI], 0.6-6.5). There were statistically significant differences between case and control fathers' use of marijuana during conception (OR = 2.2; 95% CI, 1.2-4.2; P =.01), during pregnancy (OR = 2.0; 95% CI, 1.0-4.1; P =.05), and postnatally (OR = 2.8; 95% CI, 1.1-7.3; P =.04) and the risk of SIDS, while adjusting for paternal smoking and alcohol use. CONCLUSIONS: There was no association between maternal recreational drug use and SIDS. Paternal marijuana use during the periods of conception and pregnancy and postnatally were significantly associated with SIDS. The role of paternal psychoactive drug use, especially the relationship between marijuana and SIDS, is an understudied area; however, before any definitive role for the father can be confirmed, these findings should be investigated and replicated in future studies.     

Acquisition of Streptococcus pneumoniae and nonspecific morbidity in infants and their families: a cohort study

BACKGROUND: Most children are believed to acquire Streptococcus pneumoniae asymptomatically, with only a few developing overt S. pneumoniae disease. This study investigates the relationship between acquisition of S. pneumoniae and mild nonspecific infection leading to general practitioner (GP) consultation. METHODS: A prospective birth cohort study of 213 infants assessed at home 9 times during 24 weeks by nasopharyngeal swab and parental interview was conducted. RESULTS: All positive S. pneumoniae swabs (including acquisition and carriage) were significantly associated with GP consultations for infection by the study infant compared with infants with negative swabs [odds ratio (OR), 1.6; 95% confidence interval (CI) 1.1-2.2; P = 0.005]. There was a stronger association with S. pneumoniae acquisition alone (OR 2.1; 95% CI 1.3-3.4; P = 0.001) than with carriage only (OR 1.4; 95% CI 0.9-2.0; P = 0.1). Multivariate analysis confirmed that S. pneumoniae acquisition by the study subject was independently associated with GP consultations: adjusted hazard ratio, 1.8 (95% CI 1.1-2.9); P = 0.02. A similar and independent association was found between S. pneumoniae acquisition by the study subject, and GP consultations for infection by the family (adjusted hazard ratio, 1.8; 95% CI 1.1-2.8; P = 0.01). CONCLUSION: Acquisition of S. pneumoniae by the study infant was significantly associated with GP consultations for infection by the infant or family.     

Influence of attendance at day care on the common cold from birth through 13 years of age

OBJECTIVE: To describe trends in the occurrence of the common cold during the first 13 years of life among children who attended different childcare settings early in life. DESIGN: The Tucson Children's Respiratory Study involves 1246 children enrolled at birth and followed up prospectively since May 1980 through October 1984. Children with data regarding day care use during the first 3 years of life were included in this investigation (n = 991). Parents reported the occurrence of frequent (> or = 4) colds during the past year by questionnaire when each child was 2, 3, 6, 8, 11, and 13 years of age. Child care at home (no unrelated children), at small day care (1-5 unrelated children), or at large day care (> or = 6 unrelated children) was reported retrospectively by parental questionnaire when the children were approximately 6 years old. RESULTS: After adjusting for potential confounding variables, compared with children at home those in large day care had more frequent colds at year 2 (odds ratio [OR], 1.9, 95% confidence interval [CI], 1.0-3.4; P =.04), less frequent colds at years 6 (OR, 0.3, 95% CI, 0.1-0.9; P =.02) through 11 (OR, 0.4, 95% CI, 0.1-1.2; P =.09), and the same odds of frequent colds at year 13 (OR,1.0, 95% CI, 0.3-3.8; P =.95). In addition, compared with children in large day care for 1 year or less those attending large day care for more than 2 years had more frequent colds at year 2 (OR, 1.7, 95% CI, 1.0-3.0; P =.04), less frequent colds at years 6 (OR, 0.5, 95% CI, 0.2-1.1; P =.08), 8 (OR, 0.2, 95% CI, 0.1-1.0; P =.04), and 11 (OR, 0.3, 95% CI, 0.1-1.0; P =.05); and the same odds of frequent colds at year 13 (OR, 0.9, 95% CI, 0.3-2.9; P =.80). CONCLUSIONS: Attendance at large day care was associated with more common colds during the preschool years. However, it was found to protect against the common cold during the early school years, presumably through acquired immunity. This protection waned by 13 years of age.     

Mechanism of cerebral edema in children with diabetic ketoacidosis

OBJECTIVES: Cerebral edema during diabetic ketoacidosis (DKA) has been attributed to osmotic cellular swelling during treatment. We evaluated cerebral water distribution and cerebral perfusion during DKA treatment in children. STUDY DESIGN: We imaged 14 children during DKA treatment and after recovery, using both diffusion and perfusion weighted magnetic resonance imaging (MRI). We assessed the apparent diffusion coefficients (ADCs) and measures reflecting cerebral perfusion. RESULTS: The ADC was significantly elevated during DKA treatment (indicating increased water diffusion) in all regions except the occipital gray matter. Mean reductions in the ADC from initial to postrecovery MRI were: basal ganglia 4.7 +/- 2.5 x 10(-5) mm(2)/s (P=.002), thalamus 3.7 +/- 2.8 x 10(-5) mm(2)/s, (P=.002), periaqueductal gray matter 4.3 +/- 5.1 x 10(-5) mm(2)/s (P=.03), and frontal white matter 2.0 +/- 3.1 x 10(-5) mm(2)/s (P=.03). In contrast, the ADC in the occipital gray matter increased significantly from the initial to postrecovery MRI (mean increase 3.9 +/- 3.9 x 10(-5) mm(2)/s, P=.004). Perfusion MRI during DKA treatment revealed significantly shorter mean transit times (MTTs) and higher peak tracer concentrations, possibly indicating increased cerebral blood flow (CBF). CONCLUSIONS: Elevated ADC values during DKA treatment suggests a vasogenic process as the predominant mechanism of edema formation rather than osmotic cellular swelling.     

Clinical associations of prenatal ischaemic white matter injury.

Neuropathological examinations were carried out at necropsy on 274 cases of intrauterine death or neonatal death at or before three days after birth. Fifty six (20.4%) subjects had evidence of prenatal ischaemic brain damage. On review of the maternal case notes to ascertain antenatal clinical associations there was an increased incidence of intrauterine growth retardation, either based on birth weight for gestational age (odds ratio (OR) 2.0; 95% confidence interval (CI) 1.1 to 3.7) or diagnosed antenatally (OR 2.7; 95% CI 1.3 to 5.6). Oligohydramnios was also more common (OR 2.9; 95% CI 1.2 to 7.0). The association of intrauterine growth retardation and white matter damage remained after excluding fetuses with a major congenital anomaly (OR 2.4; 95% CI 1.1 to 5.1). The findings suggest that chronic intrauterine hypoxia may be associated with damage to cerebral white matter among fetuses and infants who die. The relation between ischaemic white matter damage and cerebral palsy among survivors remains speculative.     

Can neurobehavioral examination predict the presence of cerebral injury in the very low birth weight infant?

This study examined in a regional cohort of 66 term age very low birth weight infants, the relationship between qualitative magnetic resonance imaging (MRI) measures of cerebral white and gray matter abnormalities and infant neurobehavioral functioning assessed by structured neurological examination. The diagnostic utility of the Dubowitz neonatal neurological examination in identifying children with severe cerebral abnormalities was also evaluated. Examination results revealed the presence of high rates of neurological abnormality, with 60% of infants scoring in the suboptimal range relative to infants born full term. Linear associations were found between the severity of structural cerebral abnormality on MRI and the quality of clinically rated infant neurobehavioral functioning, with increasing abnormalities being significantly associated with poorer neurological functioning. In particular, white matter abnormalities were significantly associated with lower mean tone and tone pattern scores and a tendency toward lower mean reflex scores. Gray matter abnormalities were significantly associated with lower tone and tone pattern scores and a tendency toward lower spontaneous movements and orientation/behavior scores. Finally, the Dubowitz Neonatal Neurological Examination was found to have relatively good sensitivity (88%; negative predictive value, 92%) but poor specificity (46%; positive predictive value, 34%) for identifying children with significant MRI abnormalities. Implications of these findings for the neurological evaluation of the very low birth weight infant are discussed.     

Randomized trial of systemic hypothermia selectively protects the cortex on MRI in term hypoxic-ischemic encephalopathy

Twenty-six infants with hypoxic-ischemic encephalopathy (HIE) were randomized to normothermia or to systemic hypothermia. The hypothermia group had less cortical gray matter signal abnormality on magnetic resonance imaging (MRI) (1/12 vs 7/14 infants in the normothermic group; P = .036), which may indicate differing regional benefit from systemic hypothermia.     

Infants of diabetic mothers are at increased risk for the oculo-auriculo-vertebral sequence: A case-based and case-control approach

OBJECTIVES: To determine if infants of diabetic mothers (IDM) are at increased risk for dysplastic ears and the oculoauriculo-vertebral spectrum (OAVS). STUDY DESIGN: Cases of IDM with dysplastic external ears seen at Cedars-Sinai Medical Center were combined with case series in medical literature describing similar patients. Data from a large congenital birth defects registry in Spain were analyzed, and odds ratios (OR) for infants born to either a gestational or preconceptionally diabetic mother to have one of the studied malformations were calculated with 95% confidence intervals. RESULTS: Among the 30 patients in the case series, 50.0% (15) had hemifacial microsomia; 46.7% (14) had hearing loss; 33.3% (10) had facial nerve palsy; 33.3% (10) had vertebral anomalies; 36.7% (11) had cardiovascular defects, of which 45% (5) were conotruncal defects; 26.7% (8) had renal anomalies; 13.3% (4) had limb defects (all radial ray hypoplasia); 10% (3) had DiGeorge sequence; 6.7% (2) had laterality defects; and 6.7% (2) had imperforate anus. Within the cases from the birth defects registry, the odds ratio for OAVS in infants of mothers with gestational diabetes mellitus was 2.28 (95% CI, 1.03-4.82, P =.03), and the OR for ear anomalies in these infants was 1.21 (95% CI, 0.94-1.56, P =.13). When infants of mothers with preconceptionally diagnosed type 1 or 2 diabetes were considered, the OR for OAVS was 1.50 (95% CI, 0.08-9.99, P =.49), and the OR for dysplastic ears was 0.94 (95% CI, 0.48-1.81, P =.85). CONCLUSIONS: Our data indicate that OAVS occurs with a higher incidence in IDM than in the general population. Associated problems include hearing loss, athymia, and cardiac, renal, and limb malformations. Therefore, we recommend that an IDM with features consistent with OAVS undergo a workup including hearing evaluation, skeletal survey, echocardiogram, renal ultrasonogram, and immunodeficiency workup if clinically indicated. Furthermore, noting that most of these defects occur in structures of neural crest origin, we hypothesize that poorly controlled maternal diabetes interferes with cephalic neural crest cell migration.     

The effect of the Val34Leu polymorphism in the factor XIII gene in infants with a birth weight below 1500 g

OBJECTIVES: The 34Leu polymorphism of the factor XIII gene is associated with a low rate of brain infarction and a higher incidence of primary intracerebral hemorrhage in adults. We evaluated the effect of the polymorphism on the subsequent development of isolated intracranial hemorrhage and white matter disease in preterm infants with a birth weight <1500 g (very low birth weight [VLBW] infants). STUDY DESIGN: We studied 531 VLBW infants and 301 control infants born at term. The factor XIII 34Leu polymorphism was detected by polymerase chain reaction and restriction enzyme digestion. RESULTS: Allele frequencies were not different from term and VLBW infants (Val/Val, 53.1% and 57.8%; Val/Leu, 38.8% and 37.6%; Leu/Leu, 8.0% and 4.5%, respectively). VLBW infants carrying the Leu/Val or Leu/Leu allele had a significant reduced risk of the development of white matter disease (3.6% vs 10.4% in infants without the polymorphism, P =.003). In a multivariate logistic regression analysis, only gestational age <28 weeks (odds ratio, 3.8; 95% confidence interval, 1.9-7.5; P <.001), and the factor XIII 34Leu allele (odds ratio, 0.3; 95% confidence interval, 0.1-0.7; P =.005) had significant prognostic value in predicting subsequent white matter disease. However, VLBW infants who carried the factor XIII 34Leu allele also had a moderately increased risk of the subsequent development of isolated intraventricular hemorrhage (14.3% vs 10.1% in infants without the mutation, P =.17). CONCLUSIONS: VLBW infants carrying the factor XIII 34Leu polymorphism had a decreased risk for white matter disorders.     

Grades I-II intraventricular hemorrhage in extremely low birth weight infants: effects on neurodevelopment

OBJECTIVE: To quantify the effect of grades I-II intraventricular hemorrhage (IVH) on the neurosensory and cognitive outcomes of extremely low birth weight infants. STUDY DESIGN: Of 706 extremely low birth weight infants without major malformations admitted to our center from 1992 to 2000, 537 survived to 20 months' corrected age (CA) and had cranial ultrasound studies performed, of whom 490 (91%) had complete neurodevelopmental assessments. Infants with severe cranial ultrasound abnormalities or meningitis were excluded, leaving a population of 362 infants, 258 of whom had a normal cranial ultrasound and 104 had an isolated grade I-II IVH. The groups had similar birth weight (808 vs 801 grams) and gestational age (26.5 vs 26.3 weeks). Outcomes of infants with normal cranial ultrasound were compared with those with grades I-II IVH at 20 months' CA. Outcomes included the Bayley Scales of Infant Development Mental Developmental Index (MDI) and major neurosensory abnormality. Logistic regression was used to assess the effect of grades I-II IVH on outcomes while adjusting for other risk factors. RESULTS: Extremely low birth weight infants with grades I-II IVH had a significantly lower mean MDI score than infants with normal cranial ultrasound (74 +/- 16 vs 79 +/- 14, P = .006). They had higher rates of MDI <70 (45% vs 25%; OR, 2.00; 95% CI, 1.20 to 3.30; P = .008), major neurologic abnormality (13% vs 5%; OR, 2.60; 95% CI, 1.06 to 6.36; P = .036), and neurodevelopmental impairment (47% vs 28%; OR, 1.83; 95% CI, 1.11 to 3.03; P = .018) at 20 months' CA, even when adjusting for confounding factors. CONCLUSIONS: Extremely low birth weight infants with grades I-II IVH have poorer neurodevelopmental outcomes at 20 months' CA than infants with normal cranial ultrasound. Advanced radiologic imaging may indicate additional brain injury associated with grade I-II IVH, which could explain these outcomes.     

Trends in infant bed sharing in the United States, 1993-2000: the National Infant Sleep Position study

BACKGROUND: Bed sharing with parents has been described as both beneficial to infant well-being and as a potentially lethal situation. OBJECTIVE: To examine trends in bed sharing between infants and caregivers, and the factors that influence this behavior. DESIGN: Annual nationally representative telephone surveys conducted between 1993 and 2000. SETTING: The 48 contiguous United States. PARTICIPANTS: Nighttime caregivers of infants born within 7 months prior to interview between 1993 and 2000. Approximately 1000 interviews were conducted each year for a total sample of 8453 nighttime caregivers. MAIN OUTCOME MEASURES: Where and with whom the infant usually slept at night in the preceding 2 weeks. RESULTS: Forty-five percent of infants spent at least some time at night on an adult bed in the last 2 weeks. Between 1993 and 2000, the proportion of infants usually sharing an adult bed at night increased from 5.5% to 12.8%. More than 90% of infants who "usually" slept on an adult bed shared it with their parents. In a multivariate analysis, factors associated with increased probability of routine bed sharing included: maternal age less than 18 years (odds ratio [OR] = 2.26; 95% confidence interval [CI], 1.22-4.21), maternal race or ethnicity reported as black (OR = 4.04; 95% CI, 3.04-5.36) or as Asian or "other" (OR = 2.72; 95% CI, 1.74-4.22), household income less than $20,000 (OR = 1.49; 95% CI, 1.15 = 1.92), living in the Southern states compared with living in the Midwest (OR, 1.59; 95% CI = 1.23, 2.06), and infant age less than 8 weeks (OR = 1.60; 95% CI, 1.10-2.33). Living in the Mid-Atlantic compared with the Midwest (OR = 0.63; 95% CI, 0.44-0.90), and being born with low birthweight and preterm (OR = 0.32; 95% CI, 0.14-0.74) were associated with decreased probability of routine bed sharing. CONCLUSIONS: Bed sharing as a routine practice is growing in the United States. Given that this practice seems to be widespread and strongly influenced by cultural factors, more studies of the consequences of bed sharing are needed to inform health care providers and parents on the risks and benefits.     

Randomized, double-blind trial of long-chain polyunsaturated fatty acid supplementation with fish oil and borage oil in preterm infants

OBJECTIVE: To test the efficacy and safety of long-chain polyunsaturated fatty acid (LCPUFA) supplementation with gamma-linolenic acid, a precursor of arachidonic acid, and docosahexaenoic acid in preterm infants. STUDY DESIGN: Preterm (<35 weeks, < or =2000 g birth weight) infants (n=238) randomly assigned to unsupplemented or LCPUFA-supplemented formula to 9 months after term. The main outcome measure was the Bayley Mental and Psychomotor Indexes (MDI, PDI) at 18 months after term. Safety outcome measures were anthropometry (9 and 18 months), feed tolerance, infection, and clinical complications. RESULTS: There were no significant differences in neurodevelopment between groups overall. In preplanned subgroup analyses, LCPUFA-supplemented boys had significantly higher Bayley MDI than did control boys (difference, 5.7 points; 95% CI, 0.3 to 11.1; P=.04). LCPUFA-supplemented infants showed significantly greater weight gain (difference, 310 g; 95% CI, 30 to 590 g; P=.03) and length gain (difference, 1.0 cm; 95% CI, 0.02 to 1.9; P=.05) between birth and 9 months, with greater effect in boys (weight difference at 9 months, 510 g; 95% CI, 80 to 930 g; P=.02; length difference at 18 months, 1.8 cm; 95% CI, 0.1 to 1.8; P=.03). CONCLUSIONS: This trial, using the strategy of providing gamma-linolenic acid as a source of arachidonic acid, showed efficacy for growth and for neurodevelopment in boys, with no adverse effects. These data have important implications for LCPUFA-supplementation strategy in preterm infants.     

Risk factors for intraventricular hemorrhage in very low birth weight infants in Tehran, Iran

Intraventricular hemorrhage (IVH) is an important cause of morbidity and mortality in very low birth weight (VLBW) infants; 80-90% of cases occur between birth and the third day of life. In a retrospective case control clinical study, files of all premature infants with birth weights <1500 grams admitted between April 2004 and October 2005 to the Neonatal Intensive Care Unit (NICU) of Akbar Abadi Hospital were reviewed. We determined risk factors that predispose to the development of high-grade IVH (grades 3 and 4) in VLBW infants. Thirty-nine infants with IVH grade 3 and 4 were identified. A control group of 82 VLBW infants were also selected. Prenatal data, delivery characteristics, neonatal course data and reports of cranial ultrasonography were carefully collected for both groups. Those variables that achieved significance (p<0.05) in univariate analysis were entered into multivariate logistic regression analysis. A total of 325 VLBW infants were evaluated. Mortality rate was 21.5%. Multivariate logistic analysis showed that the following factors are associated with greater risk of high-grade IVH occurrence: lower gestational age (OR: 3.72; 95% CI: 1.65-8.38), birth weight (OR: 3.42; 95% CI: 1.65-8.38), mechanical ventilation (OR: 4.14; 95% CI: 1.35-12.2), tocolytic therapy with magnesium sulfate (OR: 4.40; 95% CI: 1.10-24.5), hyaline membrane disease (HMD, OR: 3.16; 95% CI: 1.42-7.45), symptomatic hypotension (OR: 2.32; 95% CI: 1.06-5.42), hypercapnia (OR: 1.9; 95% CI: 1.1-3.4) and Apgar score at 5 minutes (OR: 1.58; 95% CI: 1.59-6.32).     

Morbidity during the first year of life in small for gestational age infants.

Postneonatal morbidity during infancy was studied in 284 small for gestational age (SGA) and 359 non-SGA term infants. None of these babies had congenital malformations and they were born to para 1 and para 2 mothers. SGA infants had an increased risk (OR: 1.7, 95% confidence interval: 1.1-2.6) of being admitted to hospital compared with non-SGA infants. The principal cause was respiratory tract infections. Increased hospitalisation among SGA infants was a factor only if the mother was a smoker-that is, smoked cigarettes at the time of conception. Among subgroups of SGA babies, there was an increased risk for infants of non-repeaters (women without a previous SGA child) (OR: 2.4, 95% CI: 1.4-3.8) and for infants with symmetric (OR: 2.0, 95% CI: 1.2-3.3) body proportions compared with non-SGA infants. The results suggest that, beginning in early pregnancy, growth retardation may have long term consequences for subsequent infant morbidity, particularly if the mother is smoker.     

Adverse events associated with neonatal exchange transfusion in the 1990s

OBJECTIVE: To determine the rates of adverse events associated with neonatal exchange transfusions performed for hyperbilirubinemia. STUDY DESIGN: Retrospective chart review of 55 neonates who underwent 66 exchange transfusions at two perinatal centers in Cleveland between 1992 and 2002. Demographic data, causes of jaundice, details of exchange method, and adverse events occurring within one week of exchange were recorded. At the time of exchange, 62% of infants had other neonatal morbidities. Outcomes were stratified according to gestational ages < or =32 weeks, 33 to 36 weeks, and > or =37 weeks. RESULTS: Overall, 74% of exchanges were associated with an adverse event. The most common events were thrombocytopenia (44%), hypocalcemia (29%), and metabolic acidosis (24%), of which 69%, 74%, and 44%, respectively, required treatment. There were two serious adverse events, both in infants with other serious neonatal morbidities: seizures in one infant and the death of a critically ill preterm infant (body weight 731 g, gestational age 25 weeks). There were no cases of sepsis, necrotizing enterocolitis, or cardiac arrest. Adverse events were more frequent in exchanges done on preterm infants: < or =32 weeks (87%), 33 to 36 weeks (78%), and > or =37 weeks (67%), and in infants with other neonatal morbidity (79% vs 57%; P=.08). Controlling for neonatal morbidity, we found the odds of an adverse event were significantly higher when both umbilical venous and arterial catheters were used compared with other methods of exchange (88% vs 58%; OR, 5.17; 95% CI, 1.1, 34.2; P=.03). CONCLUSIONS: The majority of adverse events associated with exchange transfusion are laboratory abnormalities and are asymptomatic and treatable.     

Congenital Anomalies in Singapore

Abstract A 3-year study (Jan. 1986-Dec. 1988) in the Kandang Kerbau Hospital revealed 678 infants with birth defects in 44,842 livebirths, (15.13 per 1,000 live births, 95% confidence intervals, CI 14.0–16.2). There were 161 cases with musculoskeletal abnormalities (3.5 per 1,000, 95% CI 3.06-4.19), 111 gastrointestinal system malformations (2.47 per 1,000, 95% CI 2.04-2.58), 88 chromosomal abnormalities (1.96 per 1,000, 95% CI 1.57-2.42), 78 cardiovascular system abnormalities (1.74 per 1,000, 95% CI 1.38-2.17), 73 urogenital system defects (1.63 per 1,000, 95% CI 1.28-2.05), and 52 central nervous system defects (1.16 per 1,000, 95% CI 0.87-1.52). The prevalence of cleft lip, cleft palate, and cleft lip/palate was 1.72 per 1,000, and Down's Syndrome 1 in 700. At review, six weeks later, the false positive rate was 4% in the infants with defects, and in the group of 709 normal controls (matched by race, maternal age, ward class and time/date of birth), the false negative rate was 0.84%. The strongest risk factors were a family history of birth defects (odds ratio, OR 3.3, 95% CI 1.8-6.4), and previous abnormal sibling(s) (OR 2.4, 95% CI 1.1–5.3). Other risk factors included drug intake during pregnancy (OR 1.2, 95% CI 0.8-2.0), becoming significant with ingestion during the first trimester (OR 1.4, 95% CI 1.1-1.8). Traditional medicine (mainly Chinese herbs during pregnancy) had a slightly higher risk (OR 1.4, 95% CI 1.0–2.0). The National University Hospital keeps a register of birth defects; trained nurses interview all mothers using a set questionnaire. Evaluation of 11,460 livebirths over a 3-year period (1991–1993) revealed 472 cases (41.19 per 1,000 livebirths, 95% CI 37.48-44.90) with 171 musculoskeletal defects (14.92 per 1,000 livebirths, 95% CI 12.69-17.16), 105 cardiovascular defects (9.16 per 1,000, 95% CI 7.41-10.91), 64 urogenital defects (5.58 per 1,000, 95% CI 4.22-6.95), 30 gastrointestinal defects (2.62 per 1000, 95% CI 1.68-3.55), 35 mixed system defects (3.06 per 1,000, 95% CI 2.04-4.07), and 18 chromosomal abnormalities (1.57 per 1,000, 95% CI 0.85-2.30). The prevalence of cleft lip/cleft lip and palate was 1.48 per 1,000. This higher prevalence could be due to the present practice of routine screening of every infant on the first day of life, together with a careful assessment for musculoskeletal defects, especially congenital dislocation of the hips.     

Perinatal or early-postnatal cytomegalovirus infection in preterm infants under 34 weeks gestation born to CMV-seropositive mothers within a high-seroprevalence population

In a prospective study, we evaluated the frequency, correlates, and clinical significance of perinatal or early-postnatal cytomegalovirus (CMV) infection in <34-week-gestation infants (n=95) born to CMV-seropositive mothers. None had congenital CMV infection. Overall, 21 (22.1%; 95% CI=14.2-31.8) infants were found to be infected; 10 excreted CMV at <60 days, and 11 had later excretion. Blood transfusion, birth weight, and vaginal delivery were not associated factors. Receiving natural breast milk within the first 30 days (OR=4.5, P=.02) or for >30 days (OR=7.9, P <.01) was associated with infection. Only one (4.8%) of the infected infants was symptomatic. For <34-week-gestation infants, frequency of perinatal and early-postnatal CMV infection is high. Early or prolonged exposure to breast milk is an associated factor. However, most infections are asymptomatic, indicating that CMV infection in preterm infants within such a population is a serious problem infrequently.     

Simplified PRISM III score and outcome in the pediatric intensive care unit

BACKGROUND: To evaluate the association of the PRISM III (pediatric risk of mortality) score with the infant outcome in the pediatric intensive care unit (PICU), and to determine if this score could be simplified. METHODS: A prospective cohort study was carried out with 170 infants who were consecutively admitted to the PICU. The PRISM III score with 17 physiologic variables was performed during the first 8 h of admission to the unit. Statistical analysis was done with logistic regression, odds ratios (OR) with 95% confidence intervals (95% CI), and receiver operating curve. The Alfa value was set at 0.05. RESULTS: There were 42 deaths (24.7%). The two main causes of death were septic shock (28.6%) and head trauma (16.7%). The PRISM III score had a sensitivity of 0.71, and a specificity of 0.64 as a mortality predictor. Out of the 17 physiologic variables only four of them were significant: abnormal pupillary reflexes OR 9.9 (95% CI, 3.5-28.4), acidosis OR 3.1 (95% CI, 2.0-4.9), blood urea nitrogen concentration OR 1.03 (95% CI, 1.01-1.04), and white blood cell count OR 1.02 (95% CI, 1.01-1.03). The whole logistic regression model had a coefficient of determination R(2) = 0.219, P < 0.001. CONCLUSIONS: In this setting, the PRISM III score had good sensitivity and specificity to predict mortality. This score could be simplified using only the four variables that were significant in this study. This modified PRISM III score could reduce the cost of patient care especially in developing countries PICU.     

Immigration, race/ethnicity, and social and economic factors as predictors of breastfeeding initiation

OBJECTIVE: To determine the impact of immigration status as well as race/ethnicity and social and economic factors on breastfeeding initiation. DESIGN: Cohort. SETTING: Multisite group practice in eastern Massachusetts. PARTICIPANTS: One thousand eight hundred twenty-nine pregnant women prospectively followed up in Project Viva. MAIN OUTCOME MEASURE: Whether the participant breastfed her infant. RESULTS: The overall breastfeeding initiation rate was 83%. In multivariate models that included race/ethnicity and social, economic, and demographic factors, foreign-born women were more likely to initiate breastfeeding than US-born women (odds ratio [OR], 3.2 [95% confidence interval (CI), 2.0-5.2]). In models stratified by both race/ethnicity and immigration status, and further adjusted for whether the mother herself was breastfed as an infant and the mother's parents' immigration status, US-born and foreign-born black and Hispanic women initiated breastfeeding at rates at least as high as US-born white women (US-born black vs US-born white women, OR, 1.2 [95% CI, 0.8-1.9], US-born Hispanic vs US-born white women, OR, 1.1 [95% CI, 0.6-1.9], foreign-born black vs US-born white women, OR, 2.6 [95% CI, 1.1-6.0], and foreign-born Hispanic vs US-born white women, OR, 1.8 [95% CI, 0.7-4.8]). Calculations of predicted prevalences showed that, for example, the 2.6-fold increase in odds for the foreign-born black vs US-born white women translated to an increase in probability of approximately 1.4. Higher maternal education and household income also predicted higher initiation rates. CONCLUSIONS: Immigration status was strongly associated with increased breastfeeding initiation in this cohort, implying that cultural factors are important in the decision to breastfeed. Immigrants of all races/ethnicities initiated breastfeeding more often than their US-born counterparts. In addition, US-born minority groups initiated breastfeeding at rates at least as high as their white counterparts, likely due in part to high levels of education and income as well as to access to a medical care system that explicitly supports breastfeeding.