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Antenatal corticosteroids (ANCS) may reduce the incidence of germinal matrix hemorrhage (GMH) in premature infants, but this does not appear to be related to enhanced maturity of the lungs. ANCS is sometimes administered to pregnant women in premature labor to promote fetal lung development and to reduce newborn respiratory distress. GMH is a brain hemorrhage that may occur in low-birth-weight infants. Among mothers of 239 premature infants with a low birth weight, 46 had been treated with a complete course of ANCS and 193 had been treated with an incomplete course or did not receive any treatment. All infants studied were intubated because of respiratory distress. Infants of mothers who had received the complete treatment of ANCS had a lower risk of GMH than infants whose mothers had not. The severity of respiratory distress did not correlate with the risk of GMH., Objective. To determine to what extent the reduced risk in preterm newborns of intracranial hemorrhage attributed to antenatal corticosteroids (ANCS) reflects reductions in the incidence of respiratory distress and its correlates. Methods. In a sample of 239 very low birth weight newborns recruited for a clinical trial of phenobarbital prophylaxis of subependymal/intraventricular hemorrhage, we explored the relationship between ANCS, the occurrence of germinal matrix hemorrhage (GMH) that first became evident after the 12th postnatal hour, and putative intervening variables such as acidosis, elevated peak inspiratory pressure, pneumothorax-pulmonary interstitial emphysema, and elevated continuous positive airway pressure. Results. In multivariate models adjusting for confounders, newborns exposed to ANCS were at approximately one third the risk of GMH experienced by newborns not exposed to a full course of ANCS. The additions of measures and correlates of respiratory distress severity to these models did not change the GMH risk associated with ANCS. Conclusion. The GMH-protective effect of ANCS does not appear to be a consequence of enhanced pulmonary maturation. Pediatrics 1993;91:1083-1088; corticosteroids, cerebral hemorrhage, respiratory distress syndrome, low birth weight, neonate.

Clinical and laboratory studies have demonstrated that glucocorticoid drugs are effective in treating pulmonary surfactant deficiency in premature infants (pulmonary surfactant is a phosphate and lipid compound that controls the surface tension of the lungs). Researchers questioned how glucocorticoids might affect bronchopulmonary dysplasia (BPD), the abnormal development of tissue in the lungs and bronchi. The effectiveness of glucocorticoids, given to mothers during pregnancy, to reduce the risk of infants developing BPD was assessed in newborns with low birth weights. Among 223 infants weighing less than 1,751 grams (or 3.8 pounds) at birth, 76 had bpd as indicated by chest x-ray and oxygen requirement. Low-birth-weight infants of mothers who were not treated with glucocorticoids during pregnancy had an increased risk of BPD, whereas infants of mothers who received only a partial regimen of glucocorticoid therapy were not at increased risk of BPD. Glucocorticoid treatment was shown to be beneficial for the outcome of all newborns with birth weights of l kilogram (or 2.2 pounds), with the exception of extremely low-birth-weight male infants. These findings support the hypothesis that glucocorticoid treatment of mothers during pregnancy protects infants with low birth weights against BPD. (Consumer Summary produced by Reliance Medical Information, Inc.)

Low birth weight (LBW), less than 3.6 pounds (1,750 grams), is associated with a poor infant outcome. LBW infants are at risk for periventricular-intraventricular hemorrhage, bleeding in or around the small cavities of the brain. The more severe the hemorrhage, the greater the brain damage. Phenobarbital, an anticonvulsant, is often given to control seizures in infants experiencing severe periventricular-intraventricular hemorrhage. The relationship between the location of the hemorrhage and the neurological deficit sustained has not been well-studied. The neurological outcome of 228 low birth weight infants who initially required mechanical ventilation and phenobarbital therapy to prevent seizures was evaluated. The results of ultrasonographic imaging, the use of high frequency sound to visualize internal structures, were related to motor abnormalities experienced by the surviving infants 18 months later. There were 51 infants with confirmed hemorrhage. Periventricular-intraventricular hemorrhage was related to neurological abnormalities such as decreased grasp maturity, persistent closure of the fingers, decreased parachute reaction (both arms extended when the infant is turned face-down), delayed walking, spastic palsy and abnormal movements. There was an increased risk for a neurological abnormality regardless of the type and location of the hemorrhage. The deficits were similar with and without phenobarbital prophylaxis. The most common abnormalities were abnormal jerky movements, exaggerated flexing of ankle or knee, and poor muscle tone. Infants experiencing substantial enlargement of the brain's ventricles were five times more likely to develop spastic cerebral palsy and delayed walking. They were three times more likely to have poor resistance to stretch and hyperactive, exaggerated knee-ankle reflexes. There is an increased risk for motor and reflex abnormalities among infants who experienced periventricular-intraventricular hemorrhage, particularly those infants having damage to the white matter of the brain. (Consumer Summary produced by Reliance Medical Information, Inc.)

There are three possible explanations for the high incidence of intracranial hemorrhage (bleeding in the brain) among infants born prematurely. One theory implicates respiratory distress syndrome, a condition in which the lungs are too rigid to expand. In these infants, the grunting during breathing may reflect a build-up of pressure in the brain; increased intracranial pressure may contribute to intracranial hemorrhage. The second theory implicates instrumentation, procedures and medications used to treat infants with respiratory distress syndrome; chemicals such as benzyl alcohol and heparin increase the risk for brain hemorrhage. Since respiratory distress syndrome is a condition brought about by lung immaturity, it is conceivable that intracranial hemorrhage is the result of immature blood vessels in the brain. Gestational age, the period from conception in weeks, is a measure of age, but not necessarily an indicator of maturity; maturity may vary among infants of the same gestational age. The third hypothesis states that respiratory distress syndrome does not cause intracranial hemorrhage, but it may be used to identify infants who are vulnerable to intracranial hemorrhage. Surfactant, a substance that reduces the rigidity in immature lungs, also reduces the risk of intracranial hemorrhage. Twenty-five percent of the infants who were treated with surfactant experienced a reduction in the incidence of intracranial hemorrhage. It is also possible that surfactant reduced the incidence of intracranial hemorrhage by chance. The likelihood that intracranial hemorrhage is encouraged by respiratory distress syndrome is small, and the relationship between intracranial hemorrhage and respiratory distress syndrome should not be based on current clinical trials with surfactant. (Consumer Summary produced by Reliance Medical Information, Inc.)

Abstract. Fifty-one sequential intubated babies with birth weights of less than 1,751 were evaluated by serial Doppler ultrasound during the first three days of life. These babies were part of a phenobarbital prophylaxis trial cohort study. Subependymal-intraventricular hemorrhage developed in 17 of the babies. Infants with subependymal-intraventricular hemorrhage, whether or not they received pancuronium or phenobarbital, had coefficients of variation comparable to those of babies without hemorrhage. Coefficient of variation values of the right were comparable to values obtained from the left anterior cerebral artery complex and did not appear to be consistently altered by the presence of subependymal-intraventricular hemorrhage. Coefficient of variation values appeared to be consistently greatest on day I and lowest on day 2. In addition, the values overall increased as the number of waves used to determine the coefficient of variation enlarged from five to 20. This phenomena, however, was not seen among pancuronium recipients and suggests that movement artifact may be a determinant of coefficient of variation values. We conclude that, when the best 20 waves are chosen to evaluate the coefficient of variation, no association exists between coefficient of variation values and development of subependymal-intraventricular hemorrhage or administration of phenobarbital. [ABSTRACT FROM AUTHOR]

Abstract. We enrolled 280 intubated babies with birth weights of less than 1,751 g in a double-blind randomized prospective clinical trial to evaluate whether phenobarbital influences the likelihood of developing subependymal-intraventricular-intraparenchymal hemorrhage. Phenobarbital was associated with an increased risk of developing any subependymal-intraventricular-intraparenchymal hemorrhage and was not associated with a diminished risk of either severe hemorrhage or germinal matrix hemorrhage. This increased risk was apparent even after we considered the influence of phenobarbital levels, timing of phenobarbital administrations, institutional differences, quality of ultrasound scans, gestational age- and birth weight-specific effects, ascertainment bias, and other possible confounders of phenobarbital administration. Pediatrics 1986:77:443-450; phenobarbital, hemorrhage, premature infant. [ABSTRACT FROM AUTHOR]

There is a high incidence of hemorrhage in the germinal matrix and ventricular system in premature infants. Existing systems of grading the extent of hemorrhage into germinal matrix and ventricles of premature babies have limitations. It is necessary to consider correlations of structure (neuroanatomy by ultrasound) with function (outcome of patient). It is suggested that a standardized worksheet for evaluation of cranial ultrasound usage in premature infants be adopted. Such a worksheet allows uniformity of data collection and permits a more efficient method for evaluating correlations of structure with function. Pediatrics 1984;74:358-363; intracranial hemorrhage, pediatric ultrasonography, grading systems. [ABSTRACT FROM AUTHOR]

Presents letters to the editor referencing topics and articles discussed in previous issues of "Pediatrics." Remarks regarding intraventricular hemorrhage grading; Reaction on a proposal for early feeding of premature infants.

Background: Studies of the relationship between ultrasound images from preterm newborns and developmental delay most often are based on small samples defined by birth weight and exclude infants not testable with standardized assessments., Methods: We evaluated associations between ultrasound-defined lesions of the brain and developmental delays at 24 months' corrected age in 1017 children born before the 28th postmenstrual week. Brain ultrasound scans were read for concordance on 4 lesions: intraventricular hemorrhage, moderate/severe ventriculomegaly, white matter echodense/hyperechoic lesions, and white matter echodense/hypoechoic lesions and 2 diagnoses-periventricular leukomalacia and periventricular hemorrhagic infarction. Certified examiners, who were not aware of the infants' ultrasound findings, administered the Bayley Scales of Infant Development-Second Edition. Children with an impairment (eg., blindness) that precluded testing with the Bayley Scales and those for whom >2 test items were omitted were classified using the Vineland Adaptive Behavior Scales Motor Skills Domain instead of the Psychomotor Development Index and the Adaptive Behavior Composite instead of the Mental Development Index., Results: Fully 26% of all of the children had delayed mental development (ie, Mental Development Index < 70), and 31% had delayed psychomotor development (ie, Psychomotor Development Index < 70). Ultrasound abnormalities were more strongly associated with low Psychomotor Development Index than with low Mental Development Index. Children without cranial ultrasound abnormality had the lowest probability (23% and 26%) of delayed mental or psychomotor development. Moderate/severe ventriculomegaly was associated with a more than fourfold increase in the risk of psychomotor delay and an almost threefold increase in the risk of mental delay. Echolucency was the next best predictor of delayed mental and psychomotor development. The probability of low scores varied with the number of zones involved and with the location of echolucency. At particularly high risk were infants with bilateral cerebellar hemorrhage, co-occurring ventriculomegaly and echolucency bilateral echolucency, or echolucency located posteriorly., Conclusions: Focal white matter damage, as characterized by echolucent/hypoechoic lesion, and diffuse damage, as suggested by late ventriculomegaly, are associated with delayed mental and psychomotor development.