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We describe a premature male infant who died from complications resulting from two malformations: a large left-sided diaphragmatic hernia and a right-sided cervicothoracic neurenteric cyst. The findings of the first limited prenatal ultrasound led to the incorrect diagnosis of right-sided diaphragmatic hernia. Vertebral anomalies, commonly associated with neurenteric cysts, and an intrathoracic stomach, were not identified until autopsy examination. A literature review describes only one partly similar case relating a neurenteric cyst to the jejunum associated with an ipsilateral diaphragmatic defect identified on prenatal ultrasound. The second report of this combination raises the question of a developmental relationship.

Background: Due to global immaturity, very low birthweight (VLBW) infants (Aims: Examine the association between VLBW infant body temperatures over time and respiratory support type (mechanical ventilation (MV), continuous positive airway pressure (CPAP), room air (RA)), respiratory care interventions, and nursing care. Design: Exploratory, longitudinal, and correlational design. Subjects: 12 infants Measurements: Minute-to-minute body temperatures and continuous video data were collected over the first 5 days of life. Video data was coded with Noldus Observer®XT software. Respiratory support was retrieved from the electronic health record. Hierarchical multi-level, mixed-effects models for intensive longitudinal data examined the associations. Results: Body temperatures were associated with respiratory support type, respiratory care, and care events (all p < .0001). Pairwise comparison found significant differences in body temperatures between all respiratory support types (all p < .0001). The covariate-adjusted risk of hypothermia (Conclusion: Our results found an association between VLBW infant thermal instability and respiratory support type, respiratory care, and care events. Larger studies with advanced longitudinal analysis are needed to assess the causal impact of these interventions on infant temperatures over time, as well as the implications of longitudinal thermal instability on infant outcomes.

Amplitude integrated EEG (aEEG) is increasingly utilized in preterm infants. The aim of the study was to evaluate whether semiquantitative visual assessment of aEEG background during the first 72 hours of life is associated with long-term outcome in a group of premature infants born less than 28 weeks’ gestation. Infants were prospectively enrolled and monitored in the first 72 hours after birth. aEEG was classified daily according to background activity, appearance of cyclical activity and presence of seizures activity. Log-rank and multivariable cox analysis were used to explore associations of background aEEG activity with short and long-term outcome. Overall, 51 infants were enrolled into the study. Depressed aEEG background on the third day of life was associated with poor outcome ( P = .028). Similarly, absence of cycling on the third day of life was associated with death or poor outcome ( P = .004 and .012, respectively). In different multivariable models adjusted for gestational age, severe intraventricular hemorrhage or use of sedative medication, neither background nor cycling activities were associated with outcome. Depressed aEEG background and absence of aEEG cycling on the third day of life are associated with poor outcome in univariable analysis. Although continuous aEEG monitoring of premature infants can provide real-time assessment of cerebral function, its use as a predictive tool for long-term outcome using visual analysis requires caution as its predictive power is not greater than that of gestational age or intraventricular hemorrhage.

Wallerian degeneration is defined as axonal fiber and myelin sheath degeneration that affects myelinated axons within the peripheral or central nervous system. Wallerian degeneration or anterograde axonal degeneration before myelination is rarely reported. Involvement of both corticospinal tracts (CSTs) is rarely documented in the literature. We present the postmortem neuropathologic findings of a 1-week-old male neonate born at 23 weeks of gestation with bilateral CST degeneration extending from the posterior limb of the internal capsule through the brainstem into the lumbar spinal cord. Abundant CD68- and CD163-positive macrophages were the prominent histopathology in both CSTs. The cerebrum, brainstem, and spinal cord were unmyelinated, as expected. In contrast, the spinal nerve roots demonstrated early myelination. This case illustrates that Wallerian degeneration occurs in unmyelinated axis cylinders.

It is controversial whether it is cost-beneficial for late preterm infants to receive respiratory syncytial virus prophylaxis. This study compares community and hospital health care resource utilization (HCRU) of late premature infants (33-36 weeks gestational age) with term infants (>36 weeks gestational age) hospitalized with bronchiolitis. This was a retrospective, population-based, observational study spanning a 9-year period (2004-2012). HCRU data were obtained from the Health Maintenance Organization “Clalit” and included duration of hospitalization, physician visits, laboratory tests, and treatments. Compared with term infants, late preterm infants had significantly longer duration of hospitalization and higher admission rates to pediatric intensive care unit. They also had higher rates of mean outpatients clinic visits, total outpatient clinic and specialist visits, blood chemistry, and virology testing. HCRU of term infants with bronchiolitis was also substantial, indicating that they also can greatly benefit from respiratory syncytial virus prophylaxis. These findings can guide stakeholders in decisions concerning the prevention of bronchiolitis and will be useful in performing further cost-benefit analysis.

Objective: Due to physiological and metabolic immaturity, prematurely born infants are at increased risk because of maternal separation in many neonatal intensive care units (NICUs). The stress induced from maternal–infant separation can lead to well-documented short-term physiologic instability and potentially lifelong neurological, sociological, or psychological sequelae. Based on previous studies of kangaroo mother care (KMC) that demonstrated improvement in physiologic parameters, we examined the impact of KMC on physiologic measures of stress (abdominal temperature, heart rate, oxygen saturation, perfusion index, near-infrared spectrometry), oxidative stress, and energy utilization/conservation in preterm infants. Methods: In this randomized, stratified study of premature neonates, we compared the effects on urinary concentrations of biomarkers of energy utilization and oxidative stress of 1 hr of KMC versus incubator care on Day 3 of life in intervention-group babies ( n = 26) and control-group babies ( n = 25), respectively. On Day 4, both groups received 1 hr of KMC. Urinary samples were collected 3 hr before and 3 hr after intervention/incubator care on both days. Energy utilization was assessed by measures of adenosine triphosphate (ATP) degradation (i.e., hypoxanthine, xanthine, and uric acid). Oxidative stress was assessed using urinary allantoin. Mixed-models analysis was used to assess differences in purine/allantoin. Results: Mean allantoin levels over Days 3 and 4 were significantly lower in the KMC group than in the control group ( p = .026). Conclusions: Results provide preliminary evidence that KMC reduces neonatal oxidative stress processes and that urinary allantoin could serve as an effective noninvasive marker for future studies.

This study assessed the impact of respiratory syncytial virus-confirmed hospitalizations (RSVH) on caregivers of high-risk preterm infants. Caregivers for infants born at 29 to 35 weeks' gestational age and hospitalized for confirmed RSV disease responded to measures of self-rated and perceived infant stress (1-7; 7 = very stressful), perceived infant health (0-100; 100 = best imaginable health), and productivity impairment. Data were collected at hospital discharge through 1 month post-discharge. Caregiver responses indicated high stress levels, poor health, and productivity loss were reported at discharge; however, steady improvements were seen through 1 month post-discharge: caregiver-rated stress (from 6 to 2), infant stress (5 to 1), caregiver-perceived infant health (64 to 84), and productivity loss (mothers: 91% to 31%; fathers: 81% to 18%). Qualitative results indicated emotional impact, family routine disruption, financial concerns, and medical concerns persisted at 1 month post-discharge. This study found the caregiver burden of RSVH persists at least 1 month beyond discharge.

Introduction: The prevalence of voice abnormalities in children born prematurely has been reported to be as high as 58%. Few studies have examined these abnormalities with laryngoscopic or videostroboscopic findings and characterized their laryngeal pathologies. Objective: To review voice abnormalities in patients with a history of prematurity and characterize the etiology of their voice problems. A secondary objective is to see if there is a correlation between the findings and the patient’s intubation and surgical history. Methods: A retrospective chart review was conducted of all preterm patients seen in voice clinic at a tertiary pediatric hospital. Demographic data, diagnoses, and office laryngoscopies were reviewed as well as any speech therapy evaluations and/or medical and surgical treatments. Results: Fifty-seven patients were included. Mean age at presentation was 5.1 (±4.3) years. Mean gestational age was 27.8 (±3.7) weeks. Consensus Auditory-Perceptual Evaluation of Voice (CAPE-V) perceptual evaluations included a mean overall dysphonia severity of 46.6 (±24.2). Patients who had undergone prolonged intubation (⩾28 days) in the NICU or had prolonged NICU stays (>12 weeks) had significantly higher overall dysphonia severity scores. Thirty-three patients with vocal fold hypo- or immobility had significantly greater voice deviance in breathiness, loudness, and overall severity compared to those without vocal fold immobility. Of all patients, 35% were recommended surgical intervention and 49% voice therapy. Conclusion: Intubation greater than 28 days and prolonged NICU stays are associated with more severe dysphonia in premature patients. There should be a low threshold for clinical evaluation of dysphonia in this unique patient population.

BackgroundThe aim of this retrospective study is to evaluate clinical characteristics and outcomes of very low birth weight (VLBW) neonates with acute kidney injury (AKI) treated with peritoneal dialysis (PD).MethodsThis retrospective study included 10 VLBW neonates treated with PD. Intravenous (IV) cannula and umbilical venous catheter were used for the peritoneal access.ResultsMean age at the moment of starting PD was 14.9 ± 9.3 days. Mean body weight (BW) was 825 ± 215 g. The average gestational age was 26.3 ± 1.1 weeks. The average duration of dialysis was 20.5 ± 14.7 h. The average ultrafiltration was 7.7 ± 4.2 mL/kg/h. At the moment of starting PD, the average BW was 302 ± 317g (22 ± 13%), higher than at birth (in patients who had PD started in first 2 weeks of their lives) or higher than the BW before AKI was diagnosed (patients who had PD started when they were older than 2 weeks). The main cause of AKI was sepsis ( n = 8/10). Dialysate leak was registered in 2 patients, 1 patient had peritonitis and the other had a blocked PD catheter. Six patients died during PD (severe sepsis), 1 died due to hypoxic encephalopathy and coma, and 2 patients survived. One patient (with hypoxic encephalopathy and coma) died 10 days after PD was stopped due to sepsis. The overall mortality was 80%.ConclusionAcute PD is still an appropriate treatment choice for VLBW neonates with AKI. In VLBW neonates, PD can be performed with an improvised PD system and catheters.

Introduction: Neonatal herpes infections can be extremely severe and their early recognition allows for appropriate management and increases the child’s chances of survival. Case description: We report the case of a premature infant born by vaginal delivery and transferred to intensive care after neonatal misadaptation. Examination of the fundus revealed lesions of acute bilateral retinal necrosis, strongly suggesting a herpetic etiology. Conclusions: This case highlights the clinical benefit of an ophthalmologic exam in newborns with equivocal brain lesions. Herein, the fundus examination allowed for high suspicion of herpes virus infection.

Background: The role of oxidative stress remains unclear in the multifactorial pathophysiologic mechanism of lung disease in preterm infants. Aims: The aim of this study was to examine the associations among chronic lung disease (CLD), oxidative stress, and oxygen requirements in preterm infants. Design: Prospective, longitudinal, and correlational design. Subjects: Preterm infants born at Measurements: The diagnosis of CLD was obtained from the medical record. Oxidative stress was measured using 8-hydroxydeoxyguanosine (8-OHdG) in the cord blood at birth and urine on Days 1 and 7. Oxygen requirements were measured using fraction of inspired oxygen (FIO2) recorded in the first hour after birth/admission and the average FIO2 during the first 12 hr and 7 days after birth. Descriptive statistics are presented. Comparison analyses were performed using Kruskal–Wallis and Fisher’s exact tests. Results: Infants with CLD ( n = 12) had lower gestational age ( p = .04) and weight ( p = .04) at birth, more days on the ventilator ( p = .004), and longer neonatal intensive care unit stay ( p = .04) compared to infants without CLD ( n = 19). CLD was associated with lower oxidative stress levels ( p = .03) and higher oxygen requirements during the first 12 hr ( p = .025) and on Day 7 ( p = .001). Lower oxidative stress levels on Day 7 were associated with higher oxygen requirements in the first 12 hr ( p = .01) and on Day 7 ( p = .03). Conclusion: Our results linking CLD and higher oxygen requirements with low oxidative stress contradict previous reports. Findings identify a gap in knowledge for postresuscitation oxygen therapy in preterm infants and expose the role of oxidative stress from inflammation and intermittent hypoxia in the etiology of CLD.

Preterm, low-birth-weight neonates are predisposed to metabolic bone disease (MBD). This survey aimed to assess screening, diagnostic, and treatment practices in U.S. level IIIB/IIIC neonatal intensive care units (NICUs). A 29-question anonymous online survey was e-mailed to American Academy of Pediatrics Perinatal Section members. 338 neonatologists, representing 246 IIIB/IIIC NICUs, responded. 86% reported MBD screening. Screening was primarily based on gestational age (71%), with thresholds 500 U/L (58.6%). 52% used X-ray for diagnosis. Treatment included human milk fortification (83%), vitamin D (67%), calcium (65%), and phosphorus (65%) supplementation. Our survey confirms widespread awareness of MBD but highlights lack of consensus regarding definition, screening, and treatment. Further research is needed to develop and optimize strategies to prevent, recognize, and manage MBD.

To see if the systemic inflammation profile of 123 infants born before the 28th week of gestation who had intraventricular hemorrhage without white matter injury differed from that of 68 peers who had both lesions, we compared both groups to 677 peers who had neither. Cranial ultrasound scans were read independently by multiple readers until concordance. The concentrations of 25 proteins were measured with multiplex arrays using an electrochemiluminescence system. Infants who had both hemorrhage and white matter injury were more likely than others to have elevated concentrations of C-reactive protein and interleukin 8 on days 1, 7, and 14, and elevated concentrations of serum amyloid A and tumor necrosis factor–α on 2 of these days. Intraventricular hemorrhage should probably be viewed as 2 entities: hemorrhage alone and hemorrhage with white matter injury. Each entity is associated with inflammation, but the combination has a stronger inflammatory signal than hemorrhage alone.

Transient myeloproliferative disorder (TMD) can be found in well or ill newborns with Down syndrome. Although it is a relatively harmless process for most, in some children, TMD can present as a life-threatening state requiring critical care. As the disease is seemingly uncommon, some providers may lack a sense of urgency in the dissemination of TMD awareness; however, one can never know on whose door this patient may knock tomorrow. Advanced practice professionals should be prepared for the TMD patient that may present without warning. The goals of this article are to discuss common presentations, diagnosis, and management; and to bring attention to this often de-emphasized disease.

Whether intraventricular hemorrhage increases the risk of adverse developmental outcome among premature infants is controversial. Using brain ultrasound, we identified IVH and white matter abnormalities among 1064 infants born before 28 weeks gestation. We identified adverse developmental outcomes at 24 months of age using a standardized neurological examination and the Bayley Scales of Infant Development Mental and Motor Scales. In logistic regression models that adjusted for gestational age, sex, and public insurance, isolated intraventricular hemorrhage was associated with visual fixation difficulty (odds ratio: 2.5 (95% confidence limits: 1.2, 5.1)) but no other adverse outcome. Infants who had a white matter lesion unaccompanied by intraventricular hemorrhage were at increased risk of cerebral palsy, low Mental and Motor Scores, and visual and hearing impairments. Except when accompanied or followed by a white matter lesion, intraventricular hemorrhage is associated with no more than a mild increase (and possibly no increase) in the risk of adverse developmental outcome during infancy.

Neonatal seizures can be difficult to recognize given the variation in their presentation. Hence, diagnosis and appropriate treatment may be delayed. Morphology of seizures in this age group is discussed, followed by common etiological entities. Special emphasis is laid on treatable disease states such as vitamin responsive seizure disorders and benign conditions that may not warrant aggressive treatment. Conditions that may have devastating neurological consequences are discussed in some detail so that the treating pediatrician can provide realistic information to the parents of such newborns. Imaging and laboratory workup is outlined, followed by guidelines for ordering and interpreting an electroencephalogram in this age group. Finally, treatment options in the form of antiepileptics are discussed with mention of new avenues for diagnosis and treatment that may become commonly employed in the future.

Isolated paraventricular frontal horn cysts are sometimes encountered on cranial ultrasound examinations of preterm neonates. The etiology and clinical significance of these lesions are unclear. The authors aimed to identify antenatal/intrapartum risk factors associated with the occurrence of these cysts and to assess developmental outcomes of preterm neonates with isolated frontal horn cysts. A retrospective cohort study with matched control design was used. A total of 28 cases were matched for gestation with 56 controls. No antenatal/intrapartum factors were associated with these cysts. At corrected age of 1 year, there was no difference in the mean general quotient between cases and controls (97.75 ± 17.28 vs 94.94 ± 9.86; P = .410). In all, 1 case and no controls had a diagnosis of cerebral palsy and 1 case and 3 controls had general quotients less than 80. The authors conclude that isolated paraventricular frontal horn cysts are benign, with no effect on neurodevelopment.

Objectives: We investigated risk factors associated with unilateral iatrogenic vocal fold paralysis (IVFP) in the context of ligation of patent ductus arteriosus (PDA) and compared the rates of paralysis between vascular clip and suture ligation procedures. Methods: We performed a prospective examination of infants with isolated PDA treated surgically during 1995 to 2005. Statistical significance was determined with a 2-tailed t-test. Results: Of 68 PDA ligations, 13 cases of left-sided IVFP were diagnosed, for an overall incidence of 19%. All cases of IVFP occurred in 55 infants who weighed less than 1 kg at birth. Suture ligature was used in 60% of all PDA ligation patients, and vascular clips in 40%. The incidence of IVFP in patients with vascular clips (19%) was similar to the incidence in those with suture ligature (20%). Hoarseness or stridor was present in 69% of patients with IVFP, compared to 17% of normal controls (p < 0.001). The rate of aspiration was not increased in the IVFP group; however, 15% of the patients with IVFP had episodes of decreased oxygen saturation, versus 7% of infants with normal vocal fold mobility. Conclusions: A hoarse infant with a birth weight of less than 1 kg who has undergone PDA ligation should be examined for unilateral IVFP. Vascular clips and suture ligature are associated with similar rates of IVFP.

Brain abnormality in surviving premature infants is associated with an enormous amount of neurodevelopmental disability, manifested principally by cognitive, behavioral, attentional, and socialization deficits, most commonly with only relatively modest motor deficits. The most recognized contributing neuropathology is cerebral white matter injury. The thesis of this review is that acquired cerebellar abnormality is a relatively less recognized but likely important cause of neurodevelopmental disability in small premature infants. The cerebellar disease may be primarily destructive (eg, hemorrhage, infarction) or primarily underdevelopment. The latter appears to be especially common and relates to a particular vulnerability of the cerebellum of the small premature infant. Central to this vulnerability are the extraordinarily rapid and complex developmental events occurring in the cerebellum. The disturbance of development can be caused either by direct adverse effects on the cerebellum, especially the distinctive transient external granular layer, or by indirect remote trans-synaptic effects. This review describes the fascinating details of cerebellar development, with an emphasis on events in the premature period, the major types of cerebellar abnormality acquired during the premature period, their likely mechanisms of occurrence, and new insights into the relation of cerebellar disease in early life to subsequent cognitive/behavioral/attentional/socialization deficits.

Cerebral palsy will affect nearly 10% of the 60 000 very low-birth-weight infants born in the United States in the next year, and an even greater percentage will display some form of permanent neurological impairment resulting from injury to the preterm brain. The 2008 Neurobiology of Disease in Children Symposium, held in conjunction with the 37th annual meeting of the Child Neurology Society, aimed to define current knowledge and to develop specific aims for future clinical, translational, and fundamental science. A complex interplay of both destructive and developmental forces is responsible for injury to the preterm brain. Advances in imaging and histology have implicated a variety of cell types, though preoligodendrocyte injury remains the focus. Research into different mechanisms of injury is facilitating new neuroprotective and rehabilitative interventions. A cooperative effort is necessary to translate basic research findings into clinically effective therapies and better care for these children.

Objective. To study the prevalence of major morbidities and mortality of inborn, late-preterm infants. Methods. A retrospective review was conducted from 2004 to 2008. Descriptive outcomes were compared with predefined aggregate outcomes of term infants during the same period. Results. Data on 1193 late-preterm and 8666 term infants were compared. Majority of late-preterm infants were 36 weeks (43.6%), followed by 35 weeks (29.2%) and 34weeks (27.2%), respectively. The prevalence of intensive care admission, respiratory support, pneumothorax, and mortality in late preterm infants was significantly higher compared with term infants. Mechanical ventilation and continuous positive airway pressure rates substantially decreased with increased gestational age. Although only 1.0% had positive cultures, 28.5% received parenteral antibiotics. The late-preterm group had a 12-fold higher risk of death with an overall mortality rate of 0.8%. Conclusion. This study confirmed the high-risk status of late-preterm infants with worse mortality and morbidities compared with term infants.

This article describes the short-term outcomes of late preterm neonates born between 34 and 36 (6/7) weeks gestational age (GA) in a 4-year period. A total of 1381/ 20554 (6.7%) births were between 34 and 36 weeks of GA and were predominantly Caucasian (87%). In all, 697/1381 (51%) were admitted to nursery whereas 684/1381 (49%) remained with their mothers. Of the babies born at 34, 35, and 36 weeks GA, 97%, 53%, and 32%, respectively, required admission and of these 30%, 33%, and 23%, respectively, required respiratory support. Air leaks developed in

The aim of this study was to investigate the neurodevelopmental outcome in very low birth weight infants with postnatal subependymal cysts. During a 3-year period, postnatal subependymal cysts were diagnosed by serial cranial ultrasound in 21 very low birth weight infants born prior to 33 weeks' gestation. These infants and 116 healthy very low birth weight controls were evaluated with the Bayley Scales of Infant Development at 2 years of age. Preterm infants with postnatal subependymal cysts had a significantly lower Psychomotor Development Index ( P = .034) and were more likely than the normal group to have motor developmental delay (Psychomotor Development Index

Although relations between the extent of periventricular leukomalacia and neuropsychological performance in preterm children with spastic diplegia have been extensively investigated, studies on term children with spastic diplegia are rare. The authors examined 15 preterm children and 9 term children with spastic diplegia, all of whom had periventricular leukomalacia as a main magnetic resonance imaging (MRI) finding (excluding full-term spastic diplegic children with other MRI findings). Cognitive abilities (Griffith scale) and visuoperceptual abilities (Developmental Test of Visual Perception) were compared in the 2 groups and related to periventricular leukomalacia severity. Cognitive performance was substantially similar in the 2 groups. However, the overall Developmental Test of Visual Perception scores were below normal in the preterm and were normal in the term children; furthermore, visuoperceptual abilities were differentially affected in the preterm children, with visuomotor abilities more compromised than nonmotor visuoperceptual abilities. These children had similar cognitive performance and MRI findings, so the greater visuoperceptual compromise in the preterm group suggests a direct influence of prematurity, which may have adversely influenced the reorganization of visual centers and pathways following the initial developmental insult. The strabismus present in most preterm children would also have contributed to their greater visuoperceptual compromise. The authors conclude that the management of preterm and term children should differ, with concentration on visuoperceptual skills and rehabilitation in the former.

Prematurity is associated with cerebral abnormalities that might account for poorer cognitive performance. The aim of our study was to investigate the correlations between corpus callosum reductions and neuropsychologic performance in adolescents who were born preterm. Twenty-five subjects born before 33 weeks' gestation were compared with 25 subjects born at term and of similar age, gender, and sociocultural status. All subjects underwent magnetic resonance imaging and neuropsychologic examinations. Premature subjects performed worse than controls in global cognitive functioning, verbal memory, and verbal fluency. Corpus callosum measurements showed a global reduction owing mainly to thinning in the splenium, posterior midbody, and genu. Corpus callosum size significantly correlated with gestational age, Wechsler Performance IQ, and memory performance. These results suggest that cerebral growth during infancy does not compensate for corpus callosum reduction and that this reduction reflects neuropsychologic deficit. The cognitive impairment can arise from the paucity of the complex interneuronal connections owing to fiber damage, particularly myelinated fibers. ( J Child Neurol 2006;21:406—410; DOI 10.2310/7010.2006.00106).

Severe injury to the cerebellum as a complication of extreme prematurity with extremely low birthweight was recently described in 13 children with the clinical diagnosis of cerebral palsy. We report another 10 cases of this syndrome. The clinical features include striking motor impairment and variable degrees of ataxia and athetosis or dystonia, which represent a distinct clinical type of cerebral palsy. Most are severely damaged, with cognitive, language, and motor delays. All are microcephalic, except one with hydrocephalus. Neuroimaging studies demonstrate the absence of major portions of the cerebellum involving both the inferior vermis and hemispheres. Most also have injury of a less severe nature in the cerebrum. This report indicates that this is not an uncommon outcome of extremely low birthweight infants, and we hope to encourage further investigations into the relative frequency and likely etiologies of the condition. ( J Child Neurol 2004;19:139—142).

A case is presented in which a medically fragile baby was breastfed by her foster mother. As a result, the child’s physical and emotional health were improved. The mechanisms whereby human milk improves health are well known. The act of breastfeeding may also have an analgesic and relaxant effect as a result of hormonal influences and skin-to-skin contact. Many foster babies may benefit from human milk or breastfeeding. However, the risk of disease transmission must be minimized. Provision of human milk to all medically fragile foster babies is desirable. Breastfeeding by the foster mother may be applicable in cases in which the child is likely to be in long-term care, the child has been previously breastfed, or the child’s mother expresses a desire that the infant be breastfed. However, social barriers must be overcome before breastfeeding of foster babies can become more common.

Intrauterine growth retardation plays a significant role in neurodevelopmental outcome. The assessment of general movements during the first 20 weeks is a new method for early detection of brain dysfunction. General movements in 31 infants with asymmetric intrauterine growth retardation and their appropriate for gestational age—matched controls were examined. General movements were scored as normal or abnormal by sequential videotape recordings in the writhing (term to 2 weeks), early fidgety (9—11 weeks), and late fidgety (14—16 weeks) periods. Scores were compared between the groups and correlated with neurodevelopmental outcome at 2 years. The incidence of normal general movements was lower in the intrauterine growth retarded infants than in the controls ( P < .001). Significant correlations were found between general movement quality and neurodevelopmental scores in the intrauterine growth retarded group. The fidgety movements were the most sensitive and specific for prediction of neurologic outcome. The general movement assessment can, therefore, serve as an additional tool for examining the neurologic status of the preterm and term intrauterine growth retarded infant. ( J Child Neurol 2004;19:14—18).

PurposeTo assess the influence of multiple gestation on the visual apparatus and on the general state of health of premature infants and to investigate the condition of the twin or triplet with the lowest birth weight compared to multiple gestation siblings.MethodsSeventy-seven premature twins or triplets (8 to 54 months of age) were monitored at the Verona University Ophthalmology Department from November 1995 to November 1999. In another 12 subjects (younger than 8 months), only the neonatal disease records were examined; these subjects were excluded from the ophthalmologic follow-up because they were too young to be tested reliably. The study sample was compared with 120 premature singletons monitored from January 1996 to March 1998. Visual acuity, ocular motility, strabismus, refraction defects, dioptric media, and fundus oculi were assessed.ResultsThe incidence of retinopathy of prematurity, refraction defects, or strabismus was not significantly different between premature twins or triplets and premature singletons. The twin or triplet with the lowest birth weight was more frequently affected by eye morbidity and the diseases typical of prematurity. This difference, however, was not statistically significant.ConclusionsPremature infants are at a disadvantage compared to those born at term, irrespective of multiple birth status; multiple gestation adds no risk beyond that due to prematurity.

White matter injury in premature infants with or without intraventricular hemorrhage (IVH) remains an important cause of neonatal mortality and neurologic morbidity. The contribution of apoptosis to the cellular death in white matter injury in the preterm infant is unclear. The objective of this study was to determine whether apoptosis contributes to the cellular death in premature infants with cranial ultrasound (US) evidence of IVH and asymmetric periventricular echogenicity (PVE). Brain tissue incorporating frontoparietal white matter was obtained from 21 infants: 6 infants with severe IVH and asymmetric PVE (grade 1V IVH) on US (group 1); 9 infants with minimal IVH or normal US who died within 21 days (group II); and 6 infants with minimal IVH or normal US who died later (group III). The presence of DNA fragmentation, typical of apoptosis, was determined using a terminal deoxytransferase-mediated dUTD nick-end labeling (TUNEL) assay. The TUNEL index for group I infants was significantly greater, i.e., 2.75 +/- 1.94% versus 0.84 +/- 0.70% for group II and 0.42 +/- 0.22 for group III infants (P = 0.004). Most cells showing reactivity had morphologic characteristics consistent with astrocytes and oligodendroglia. The number of white matter cells showing morphologic changes consistent with apoptosis, such as nuclear blebs and karyorrhexis, was also quantitated and was significantly more numerous in group I than in group II infants, i.e., 0.51 +/- 0.64% versus 0.02 +/- 0.05% (P = 0.0005), and group III infants, i.e., 0.10 +/- 0.18% (P = 0.03). These findings implicate apoptosis as a contributing mechanism for the cellular death in infants with IVH and asymmetric PVE. Strategies aimed at preventing the white matter injury will need to incorporate methods of inhibiting the ongoing process of apoptosis.

Purpose: To evaluate MR findings at subacute and chronic stages after neonatal periventricular-intraventricular hemorrhage (PIVH), and to determine the clinical significance of follow-up MR. Material and Methods: Twenty-six children (estimated gestational age, 23-39 weeks; mean 29 weeks) with a history of previous PIVH underwent MR examination during their subacute and chronic clinical courses. PIVHs were initially detected with ultrasound examination in all cases. PIVH was divided into three grades (mild, moderate, and severe) according to the findings at the initial US studies, which were correlated to the MR findings. Results: Abnormal signal intensities related to hemorrhage were demonstrated in 10 of 21 patients (47.6%) on initial MR studies; the very low signal intensities on T2-weighted images found on the periventricular wall with a linear or a spotty shape had disappeared at one year after the initial US. The children with ventriculomegaly and periventricular leukomalacia (PVL) were increased in number on the follow-up studies. Conclusion: MR imaging provided valuable information about the consequences of neonatal PIVH such as developments of ventriculomegaly or PVL. It is noteworthy that hemorrhagic lesions could not be detected in half of the cases at the subacute or chronic stage of PIVH.

The objective of this study was to evaluate to what extent (1) the characteristics of localization, distribution, and size of echodense and echolucent abnormalities enable individuals to be designated as having either periventricular hemorrhagic infarction or periventricular leukomalacia and (2) the characteristics of periventricular hemorrhagic infarction and periventricular leukomalacia are independent occurrences. The population for this study consisted of 1607 infants with birthweights of 500 to 1500 g, born between January 1991 and December 1993, who had at least one cranial ultrasound scan read independently by at least two ultrasonographers. The ultrasound data collection form diagrammed six standard coronal views. The cerebrum was divided into 17 zones in each hemisphere. All abnormalities were described as being echodense or echolucent and were classified on the basis of their size, laterality, location, and evolution. Eight percent (134/1607) of infants had at least one white-matter abnormality. The prevalence of white-matter disease decreased with increasing gestational age. Most abnormalities were small or medium sized and unilateral; only large echodensities tended to be bilateral and asymmetric. Large abnormalities, whether echodense or echolucent, were more likely than smaller abnormalities to be widespread, and the extent of cerebral involvement was independent of whether abnormalities were unilateral or bilateral. Large abnormalities were relatively more likely than small abnormalities to involve anterior planes. Small abnormalities, whether echodense or echolucent, or whether unilateral or bilateral, preferentially occurred near the trigone. Using the characteristics of location, size, and laterality/symmetry, we were able to allocate only 53% of infants with white-matter abnormalities to periventricular hemorrhagic infarction or periventricular leukomalacia. Assuming that periventricular leukomalacia and periventricular hemorrhagic infarction are independent and do not share risk factors, and that each occurs in approximately 5% of infants, we would have expected 0.25%, or about 4 individuals, to have abnormalities with characteristics of both periventricular leukomalacia and periventricular hemorrhagic infarction, whereas we found 63 such infants. Most infants with white-matter disease could not be clearly designated as having periventricular hemorrhagic infarction or periventricular leukomalacia only. Periventricular hemorrhagic infarction contributes to the risk of periventricular leukomalacia occurrence, or the two sorts of abnormalities share common risk antecedent factors. The descriptive term echodense or echolucent and the generic term white-matter disease of prematurity should be used instead of periventricular leukomalacia or periventricular hemorrhagic infarction when referring to sonographically defined white-matter abnormalities. (J Child Neurol 2001;16:401-408).

Background. Gestational age (GA) and birth weight (BW) criteria are used to identify newborns at risk for neonatal morbidity. Currently, preterm is GA less than 37 weeks; low birth weight is BW less than 2,500 grams; and small for gestational age (SGA) is BW less than the tenth percentile weight for the infant's GA. The optimal classification system balances the misclassification cost of false negatives against the cost of false positives. Objective. To calculate the relative misclassification costs implied by the current 37-week and 2,500-gram cutoffs, and to test the validity of the current definition of SGA as a predictor of term morbidities. Methods. GA, BW, and morbidity information were collected for 22,606 infants born between July 1981 and December 1992. Using this dataset, logistic regression coefficients were obtained modeling GA or BW as predictors of morbidities associated with prematurity. For a subset of 18,813 infants with GAs between 37 and 41 weeks, coefficients were obtained modeling both GA and BW as independent predictors of term morbidities. The logistic regression coefficients were used to calculate optimal birth weight, gestational age, and birth-weight-for-gestational-age cutoffs. Results. The current definitions of low birth weight and preterm imply that it is 18 to 28 times more costly to misclassify a sick infant as low-risk than to misclassify a well infant as high-risk. Conclusions. Gestational age alone is better than birth weight alone at predicting preterm morbidities. No birth-weight cutoff can adequately predict term morbidities. A single weight-percentile cutoff for all gestational ages should not be used to identify newborns at high risk for neonatal morbidity. Key words: gestational age; birth weight; neonatology; logistic models; ROC curve analysis. (Med Decis Making 2000;20:369-376)

Many preterm infants cared for in incubators do not experience Kangaroo Care (KC), skin-to-skin contact with their mothers, due to fear of body heat loss when being held outside the incubator. A randomized clinical trial of 16 KC and 13 control infants using a pretest-test-posttest design of three consecutive interfeeding intervals of 2.5 to 3.0 h duration each was conducted over 1 day. Infant abdominal and toe temperatures were measured in and out of the incubator; maternal breast temperature was measured during KC. Repeated measures ANOVA showed no change in abdominal temperature across all periods and between groups. Toe temperatures were significantly higher during KC than incubator periods, and maternal breast temperature met each infant’s neutral thermal zone requirements within 5 min of onset of KC. Preterm infants similar to those studied here will maintain body warmth with up to 3 h of KC.

Apnea of prematurity (AOP) is a common problem that affects premature infants and, to a lesser degree, term infants. Apnea of prematurity appears to be due to immaturity of the infant's neurologic and respiratory systems. Apnea of prematurity is a diagnosis of exclusion that can be made only when other possible infectious, cardiologic, physiologic, and metabolic causes of apnea have been ruled out. The fundamental principles for managing apnea of prematurity include monitoring the infant closely while instituting supportive care measures such as tactile stimulation, continuous positive airway pressure, or mechanical ventilation. When necessary, pharmacologic therapy may be used to stimulate breathing. The first-line agents of choice for the management of AOP are the methylxanthines. And, for second-line therapy, a switch to a different class of agent, such as the respiratory stimulant doxapram, is an option. Of the methylxanthines, theophylline is the most extensively used. However, a review of the literature suggests that caffeine citrate may be the agent of choice for AOP. Comparative clinical studies have demonstrated that caffeine is at least as effective as theophylline, has a longer half-life, is associated with fewer adverse events, and, in addition, has a greater ease of administration. Caffeine stimulates the respiratory and central nervous systems more effectively and penetrates into the cerebrospinal fluid more readily than theophylline. In addition, because of stable plasma levels, caffeine has a wide therapeutic margin and few side effects. In contrast, theophylline plasma levels may fluctuate widely, which necessitates frequent monitoring and has a higher incidence of adverse events than caffeine. Before the FDA approval of caffeine citrate (Cafcit®) for administration either intravenously and/or orally, caffeine preparations were “homemade.” A few studies suggest that use of pharmacotherapy to treat AOP is not generally associated with long-term sequelae, although more data are needed before this can be definitively concluded.

OBJECTIVE: To review the efficacy and safety of inhaled furosemide in the treatment of acute respiratory distress and possible bronchopulmonary dysplasia (BPD) in preterm neonates receiving ventilator and oxygen support. DATA SOURCES: A MEDLINE search was performed from January 1966 to December 1998 using the key words inhaled or aerosolized furosemide, BPD, preterm, neonate, and infant newborn. STUDY SELECTION AND DATA EXTRACTION: All clinical trials involving the use of inhaled furosemide in ventilator- and oxygen-dependent preterm neonates with acute respiratory distress and possible BPD were evaluated. DATA SYNTHESIS: Inhaled furosemide 1 and 2 mg/kg has improved pulmonary function in preterm neonates without significant adverse effects. However, only a single dose of inhaled furosemide was used in these trials, and pulmonary functions were monitored for only two or four hours after administration. CONCLUSIONS: Inhaled furosemide may be effective, but studies are needed to determine the optimal dosage regimen and long-term risks and benefits of its use in these patients.

In an attempt to determine cranial ultrasonographic features of preterm infants with intraventricular hemorrhage (IVHI) and/or periventricular white matter abnormalities (PVWMA) that could serve as more specific predictors of cerebral palsy (CP), we reviewed the cranial sonograms of 34 infants with IVH and/or PVWMA. Fourteen of the 34 infants studied (41%) developed CP. One of five infants with grade III LVH alone developed CP. Eleven infants with PVWMA did not develop cysts and only two (18%) developed CP (p=0.04). Of the 18 infants who went on to develop cysts, four had a small, discrete solitary cyst and 14 had large cystic areas. Three of the four with small cysts were neurologically normal, whereas only three of the 14 with large cysts were neurologically normal (p=0.04). Preterm infants with grade III IVH in the absence of any parenchymal lesion had a more favorable neurologic outcome than those with IVH and concomitant PVWMA. Infants with PVWMA in the presence or absence of IVH had much poorer neurologic prognoses. In infants with PVWM abnormalities, both the presence and extent of cystic lesions, though not their location, are the strongest predictors of long-term neurologic outcome.

Neonatal morbidity and mortality still poses a serious challenge in developing countries. Low level of obstetric care, unsupervised home deliveries and late referrals lead to poor outcome even in special care baby units (SCBU). To identify the common causes of neonatal morbidity and mortality among babies admitted to the SCBU in Aminu Kano Teaching Hospital (AKTH) the case-notes of all admitted neonates from January 1998 to December 2004 were retrospectively reviewed. A total of 2963 (98.3%) babies had complete records. There were 1455 (49.1%) in-born (delivered in AKTH) and 1508 (50.9%) out-born (delivered elsewhere) babies. The sex ratio was1.25:1in favour of males. A total of1868 (63.0%) were of normal birth weight, while 951 (32.1%) and 134 (4.5%) were low birth weight and macrocosmic, respectively. The leading diagnoses were birth asphyxia (27%) (severe birth asphyxia 18.1%, moderate asphyxia 8.9%), neonatal sepsis (25.3%) and prematurity (16.0%). Out of the 2963 babies, 501 (16.9%) died. The risk of dying was significantly higher (20.5%) among out-born babies compared with those delivered in AKTH (6.4%) (odds ratio = 1.71, 95% confidence interval = 1.4-2.1). In conclusion, the causes of neonatal morbidity and mortality at this centre are similar to those reported from other units. They could be prevented through effective antenatal care, supervised delivery and appropriate care and early referral of sick neonates.

Although a developing country, China has a lower occurrence of low birth weight (LBW) than many developed countries. This study of two population-based one-year birth cohorts, from Finland in 1985-86 and China in 1992, shows the occurrence of low birth weight (LBW) (1000-2500 g) among singletons to be 2.6 percent in the Chinese cohort and 3.0 percent in the Finnish one, and that of preterm births (28-37 weeks) 2.7 percent and 4.5 percent, respectively. The main component of LBW is term LBW (57.4 percent) in the Chinese case and preterm LBW (64.7 percent) in the Finnish case. The perinatal mortality rate (PMR) was twice as high in the Chinese cohort (13.0 vs. 5.9 per thousand). The occurrence of LBW in the Finnish cohort decreased to 2.3 percent after crosstabulation of the Finnish mothers to conform in structure to the population of Chinese mothers in terms of maternal age, marital status and maternal smoking. The result suggests that the lower incidence of LBW in the Chinese cohort seems to be a reflection of the Chinese socio-cultural environment, which provides Chinese mothers with favourable characteristics. The Finnish excess LBW would have disappeared if the mothers had possessed those characteristics as well. The excess perinatal deaths in the Chinese series might be explained by the different levels of perinatal health care in the two countries.Even though China is a developing country, it has a lower occurrence of low birth weight (LBW) than many developed countries. The incidence of LBW, preterm births, and perinatal mortality was assessed in a cohort of 9391 children born in 1992 in Qingdao, China, and a cohort of 9479 children born in 1985-86 in Northern Finland. 2.6% of the singleton children in the Chinese cohort and 3.0% in the Finnish one were born LBW, while the occurrence of preterm births was 2.7% and 4.5%, respectively. The main component of LBW is term LBW (57.4%) in the Chinese cohort and preterm LBW (64.7%) in the Finnish cohort. The perinatal mortality rate (PMR) was 13.0/1000 in the Chinese cohort compared to 5.9/1000 in the Finnish cohort. However, after cross-tabulating the population of Finnish mothers to conform in structure to the population of Chinese mothers in terms of maternal age, marital status, and maternal smoking, the occurrence of LBW in the Finnish cohort decreased to 2.3%. The lower incidence of LBW in the Chinese cohort therefore seems to be a reflection of the Chinese sociocultural environment, which provides Chinese mothers with favorable characteristics in terms of age, marital status, and smoking. The excess perinatal mortality in the Chinese cohort may be explained by the different levels of perinatal health care in the two countries.

Previous reports have demonstrated that premature infants are at greatly increased risk for sudden infant death syndrome (SIDS). Although only 9% of infants are born at less than 36 weeks' gestation, 20% of SIDS victims are former premature infants. The objective of this study was to characterize the time course of SIDS in premature infants and to determine why SIDS occurs at such a high rate in this patient population. A database of all cases of SIDS in Philadelphia from 1987 through 1991 was used to establish the time course for SIDS deaths in term and preterm infants. Gestational age was established by Dubowitz exam. To evaluate distinctly different age groups, infants from 32-36 weeks were excluded from analysis. Age at death and postconceptional age of death were compared for both groups. Data are described in weeks (mean ± SEM), and analyzed using unpaired t-test and log-rank test to compare survival rate between term and preterm infants. A significant difference (P

This study examined whether a neurologic examination at 6 months of age is predictive of neurodevelopmental outcome at 12 months in very-low-birth-weight (VLBW) infants. A neurologic examination and the Bayley Scales of Infant Development were performed at 6 and 12 months with VLBW infants and full-term (FT) controls. VLBW infants were categorized based on early medical complications. High-risk (HR) infants had diagnoses of bronchopulmonary dysplasia, pulmonary immaturity, grade III or IV intraventricular hemorrhage, and/or periventricular leukomalacia. VLBW infants with other diagnoses were placed in the low-risk (LR) group. Total neurologic scores (NS) improved over time for all three groups but improved more for HR infants, who had more abnormal NS at both time points; NS at 6 months predicted neurologic and developmental scores at 12 months for all three groups, but the relation between 6-and 12-month outcomes was strongest for the HR infants. The neurologic examination may be helpful in assessing VLBW infants' need for referral to early childhood intervention programs.