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- Predictive Value of the Parent-Completed ASQ for School Difficulties in Preterm-Born Children <35 Weeks' GA at Five Years of Age. [JOURNAL ARTICLE]
- Neonatology 2014 Aug 23; 106(4):311-316.
Background: Preterm infants are at greater risk of developmental impairment and require close follow-up for early and optimal care. Objectives: The objective of the present study was to determine from which age the parental Ages and Stages Questionnaire (ASQ) allows detection of school difficulties in preterm children <35 weeks' gestational age. Methods: Preterm children from the regional Loire Infant Follow-up Team network were evaluated with the Global School Adaptation (GSA) assessment tool at 5 years of age and at least one parental-completed ASQ at 18, 24, or 36 months. Children belonging to the first decile of the GSA score (<38) were considered to have severe school difficulties. Using overall ASQ scores as continuous variables, receiver operating characteristic (ROC) curves were generated at every age in order to identify preterm children with severe school difficulties. Results: GSA scores were obtained in 1,775 infants at 5 years of age, and at least one ASQ score at 18, 24, or 36 months was completed. Upon ROC analysis, we observed that the 18-, 24-, and 36-month ASQ scores produced respective area under the ROC curve values of 0.66 (0.64-0.69), 0.72 (0.70-0.75), and 0.77 (0.75-0.80) for predicting a GSA score in the first decile. An ASQ cutoff value of 255 at 36 months showed optimal discriminatory power for identifying significant school difficulties at 5 years of age. Conclusions: The 36-month ASQ is a simple and cost-effective tool that can be employed to help predict future severe school difficulties at 5 years of age in preterm-born children. © 2014 S. Karger AG, Basel.
- Early and Late Complications of Germinal Matrix-Intraventricular Haemorrhage in the Preterm Infant: What Is New? [JOURNAL ARTICLE]
- Neonatology 2014 Aug 20; 106(4):296-303.
Germinal matrix-intraventricular haemorrhage (GMH-IVH) remains a serious problem in the very and extremely preterm infant. This article reviews current methods of diagnosis, treatment and neurodevelopmental outcome in preterm infants with low-grade and severe GMH-IVH. We conclude that there is still no consensus on timing of intervention and treatment of infants with GMH-IVH, whether or not complicated by post-haemorrhagic ventricular dilatation. The discrepancies between the studies underline the need for international collaboration to define the optimal strategy for these infants. © 2014 S. Karger AG, Basel.
- Necrotizing Enterocolitis: The Mystery Goes On. [JOURNAL ARTICLE]
- Neonatology 2014 Aug 20; 106(4):289-295.
Necrotizing enterocolitis (NEC) has largely been present in neonatal intensive care units for the past 60 years. NEC prevalence has corresponded with the continued development and sophistication of neonatal intensive care. Despite major efforts towards its eradication, NEC has persisted and appears to be increasing in some centers. The pathophysiology of this disease remains poorly understood. Several issues have hampered our quest to develop a better understanding of this disease. These include the fact that what we have historically termed 'NEC' appears to be several different diseases. Animal models that are commonly used to study NEC pathophysiology and treatment do not directly reflect the most common form of the disease seen in human infants. The pathophysiology appears to be multifactorial, reflecting several different pathways to intestinal necrosis with different inciting factors. Spontaneous intestinal perforations, ischemic bowel disease secondary to cardiac anomalies as well as other entities that are clearly different from the most common form of NEC seen in preterm infants have been put into the same database. Here I describe some of the different forms of what has been called NEC and make some comments on its pathophysiology, where available studies suggest involvement of genetic factors, intestinal immaturity, hemodynamic instability, inflammation and a dysbiotic microbial ecology. Currently utilized approaches for the diagnosis of NEC are presented and innovative technologies for the development of diagnostic and predictive biomarkers are described. Predictions for future strategies are also discussed. © 2014 S. Karger AG, Basel.
- Fetal Growth Restriction Is Worse than Extreme Prematurity for the Developing Lung. [JOURNAL ARTICLE]
- Neonatology 2014 Aug 20; 106(4):304-310.
Background: Perinatal lung growth is highly vulnerable to inflammation and intrauterine growth restriction (IUGR), two major risk factors for chronic lung disease (CLD) in preterm neonates. However, the balance between extremely low gestational age (ELGA) and IUGR in very preterm infants as risk factors for CLD and co-morbidities remains poorly explored. Objectives: This single-center study aims to compare neonatal morbidity (including CLD) and mortality among ELGA infants with normal birth weight (ELGA-AGA), very preterm infants with IUGR <3rd percentile (VLGA-IUGR) and very preterm infants with a birth weight appropriate for gestational age (VLGA-AGA), matched with VLGA-IUGR infants. Methods: Selected characteristics of the perinatal and neonatal periods were recorded and retrospectively compared among the three groups. Infants with major congenital anomalies were excluded. The diagnosis of CLD was based on whether the infant was receiving supplemental oxygen and/or non-invasive ventilation at a postmenstrual age of 36 weeks. Results: We found that, despite a median difference of 3 weeks in gestational age at birth between VLGA-IUGR and ELGA-AGA infants, neonatal mortality was 35% higher in neonates who had experienced fetal growth restriction, and that VLGA- IUGR was five times more predictive of CLD than was ELGA-AGA. These differences persisted after adjustment for confounding factors such as antenatal steroids, gender and respiratory distress syndrome. Conclusions: This study reports that VLGA-IUGR infants are at higher risk of neonatal mortality and CLD than both ELGA-AGA and VLGA-AGA infants. © 2014 S. Karger AG, Basel.
- The Quality of General Movements after Treatment with Low-Dose Dexamethasone in Preterm Infants at Risk of Bronchopulmonary Dysplasia. [JOURNAL ARTICLE]
- Neonatology 2014 Jul 5; 106(3):222-228.
Background: High-dose dexamethasone (DXM) treatment of preterms at risk of bronchopulmonary dysplasia leads to a deterioration in quality of their general movements (GMs). It is unknown whether low-dose DXM affects GM quality similarly. Objectives: To assess the effect of low-dose DXM treatment on the quality of GMs and fidgety GMs (FMs). Methods: A prospective study of preterms admitted to our NICU between 2010 and 2012, and treated with DXM (starting dose 0.25 mg/kg/day). We assessed GM/FM quality and calculated their motor optimality score (MOS) before, during, and after treatment up to 3 months postterm. Neurological follow-up was performed between 12 and 36 months. We related risk factors with infants' GM trajectories and MOSs. At 3 months we compared the MOSs of low-dose DXM infants and a historical cohort of infants treated with high-dose DXM or hydrocortisone. Results: 17 infants were included. GM/FM quality improved in 9 out of 13 initially abnormal infants (p = 0.004). Shorter periods of mechanical ventilation and higher birth weights were associated with better GM trajectories (p = 0.032 and p = 0.042, respectively). Infants starting treatment later had higher MOSs on day 7 (p = 0.047). Low-dose DXM infants had higher MOSs than high-dose DXM infants (β = -0.535; 95% CI -0.594 to -0.132; p = 0.003). Out of 17 infants, 2 died, 14 developed normally, and 1 developed with mild neurodevelopmental impairments. Infants whose GMs/FMs remained normal or improved had better outcomes than infants whose GMs/FMs remained abnormal (p = 0.019). Conclusions: Out of the 17 infants treated with low-dose DXM, 2 died. Of the surviving infants, neurological functioning improved with the majority having normal neurodevelopment at the age of 12-36 months. © 2014 S. Karger AG, Basel.
- Low-Flow Oxygen for Positive Pressure Ventilation of Preterm Infants in the Delivery Room. [JOURNAL ARTICLE]
- Neonatology 2014 Jul 5; 106(3):216-221.
Background: The recent newborn resuscitation guidelines have recommended that a pulse oximeter and oxygen blender be used to keep oxygen saturation (SpO2) within the target range. However, an oxygen blender and compressed air are not generally available in delivery rooms. Objectives: To determine whether using low-flow oxygen at 0.5-1 liters/min for positive pressure ventilation (PPV) via a self-inflating bag (SIB) without a reservoir is effective and able to maintain SpO2 within the target range. Methods: Infants with a gestational age (GA) ≤32 weeks who initially required PPV after birth were enrolled. PPV was performed with low-flow oxygen at 0.5-1 liters/min via an SIB without a reservoir, and the flow was adjusted in a stepwise manner (from 0.5 to 0.8 to 1 liters/min) to keep SpO2 in the target range. If the heart rate was still <100/min or SpO2 was <70% at 3 min or chest compression was needed, then 100% oxygen was provided. Results: Forty-seven infants were enrolled in the study with a median (interquartile range) GA and birth weight of 28 (27-30) weeks and 1,060 (770-1,360) g, respectively. Twelve infants were initially intubated and switched to 100% oxygen (n = 12) due to ineffective ventilation, which occurred predominately in lower GA infants with intrapartum fetal distress. Thirty infants were successfully resuscitated with low-flow oxygen PPV (success rate 85.7%, 30/35), and >80% of their SpO2 distribution during PPV was between the 3rd and 97th percentiles of the reference range. Conclusion: Low-flow oxygen for PPV via an SIB used in this study should be sufficient for providing oxygen in resuscitation of preterm infants as long as adequate ventilation is evident. This technique is simple and could be useful in a resource-limited setting. © 2014 S. Karger AG, Basel.
- Hypoxic/Ischemic and Infectious Events Have Cumulative Effects on the Risk of Cerebral Palsy in Very-Low-Birth-Weight Preterm Infants. [JOURNAL ARTICLE]
- Neonatology 2014 Jul 5; 106(3):209-215.
Background: Hypoxia/ischemia and inflammation are two major mechanisms for cerebral palsy (CP) in preterm infants. Objective: To investigate whether hypoxia/ischemia- and infection-related events in the perinatal and neonatal periods had cumulative effects on CP risk in very-low-birth-weight (VLBW) premature infants. Methods: From 1995 to 2005, 5,807 VLBW preterm infants admitted to Taiwan hospitals were enrolled. The cumulative effects of hypoxic/ischemic and infectious events during the perinatal and neonatal periods on CP risk at corrected age 24 months were analyzed. Results: Of the 4,355 infants with 24-month follow-up, 457 (10.5%) had CP. The CP group had significantly higher incidences of hypoxia/ischemia-related events in the perinatal and neonatal periods, and sepsis in the neonatal period than the normal group. Three hypoxic/ischemic events, including birth cardiopulmonary resuscitation (OR 2.25; 95% CI 1.81-2.82), patent ductus arteriosus (PDA) ligation (2.94; 1.35-5.75) and chronic lung disease (3.14; 2.61-3.85) had the most significant contribution to CP. Relative to CP risk for infants with neither the three hypoxic/ischemic events nor sepsis, the CP odds increased 1.98-, 2.26- and 2.15-fold for infants with birth cardiopulmonary resuscitation, PDA ligation and chronic lung disease, respectively; while the combination with sepsis further increased the odds to 3.18-, 3.83- and 3.25-fold, respectively. Using the three hypoxic/ischemic events plus sepsis, CP rates were 10.0, 16.7, 26.7, 40.0 and 54.7% for infants with none, one, two, three and four events, respectively. Conclusions: Hypoxic/ischemic and infectious events across the perinatal and neonatal periods exerted cumulative effects on CP risk in VLBW premature infants. © 2014 S. Karger AG, Basel.
- Educating Neonatal Nurses in Brazil: A Before-and-After Study with Interrupted Time Series Analysis. [JOURNAL ARTICLE]
- Neonatology 2014 Jul 5; 106(3):201-208.
Background: Preterm birth contributes significantly to infant mortality and morbidity, including blindness from retinopathy of prematurity (ROP). Access to intensive neonatal care is expanding in many countries, but care is not always optimal, one factor being that nursing is often by inadequately trained nurse assistants. Objective: The aim of this study was to evaluate whether an educational package for nurses improves a range of outcomes including survival rates and severe ROP in 5 neonatal units in Rio de Janeiro, Brazil. Methods: The study design included an uncontrolled before-and-after study in 5 units, with interrupted time series analysis. Participatory approaches were used to develop a self-administered educational package for control of pain, oxygenation, infection, nutrition, and temperature and to improve supportive care ('POINTS of Care'). Educational materials and DVD clips were developed and training skills of nurse tutors were enhanced. There were two 1-year periods of data collection before and after a 3-month period of self-administration of the education package. Results: Overall, 74% of 401 nurses and nurse assistants were trained. A total of 679 and 563 infants were included in the pre- and post-training periods, respectively. Despite improvement in knowledge and nursing practices, such as the delivery and monitoring of oxygen, there was no change in survival (pre-training 80%, post-training 78.2%), severe ROP (1.6 vs. 2.8%), sepsis (11.3 vs. 12.3 cases per 1,000 infant days) or other outcomes. Outcomes worsened over the pre-intervention period but the change to an improvement after the intervention was not statistically significant. During the study period many trained staff left the units, but few were replaced. Conclusions: Future studies need to focus on barriers to implementation, team building, leadership and governance, as well as the acquisition of knowledge and skills. © 2014 S. Karger AG, Basel.
- Early Detection of Impending Necrotizing Enterocolitis with Urinary Intestinal Fatty Acid-Binding Protein. [JOURNAL ARTICLE]
- Neonatology 2014 Jul 5; 106(3):195-200.
Background: Necrotizing enterocolitis (NEC) is diagnosed after the development of feeding intolerance and characteristic physical and imaging findings. Earlier detection of a subclinical prodrome might allow for the institution of measures that could prevent or attenuate the severity of the disease. Objectives: We sought to determine whether urinary intestinal fatty acid-binding protein (iFABPu) might be elevated prior to the first clinical manifestations of NEC. Methods: Urine was collected daily from 62 infants of a gestational age of 24-28 weeks. Based on clinical, imaging and operative findings, subjects were determined to have Bell stage 2 or 3 NEC. In all the subjects with NEC and in 21 age-matched controls, iFABPu was determined using an ELISA, and was expressed in terms of its ratio to urinary creatinine (Cr), i.e. iFABPu/Cru. Receiver operating characteristic (ROC) curves were constructed to define the predictive value of iFABPu/Cru for impending NEC in the days prior to the first clinical manifestations. Results: Five subjects developed NEC (stage 2: n = 3 and stage 3: n = 2). The day before the first clinical manifestation of NEC, a ROC curve showed that an iFABPu/Cru >10.2 pg/nmol predicted impending NEC with a sensitivity of 100% and a specificity of 95.6%. iFABPu/Cru did not predict NEC 2 days prior to the first sign of disease. Conclusions: An elevated iFABPu was a sensitive and specific predictor of impending NEC 1 day prior to the first clinical manifestations. iFABPu screening might identify infants at a high risk and allow for the institution of measures that could ameliorate or prevent NEC. © 2014 S. Karger AG, Basel.
- Platelet counts in the first seven days of life and patent ductus arteriosus in preterm very low-birth-weight infants. [Journal Article]
- Neonatology 2014; 106(3):188-94.