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Objective. The Newborn Individualized Developmental Care and Assessment Program (NIDCAP) is widely used in neonatal intensive care units and comprises 85 discrete infant behaviors, some of which may communicate infant distress. The objective of this study was to identify developmentally relevant movements indicative of pain in preterm infants. Methods. Forty-four preterm infants were assessed at 32 weeks' gestational age (GA) during 3 phases (baseline, lance/squeeze, and recovery) of routine blood collection in the neonatal intensive care unit. The NIDCAP and Neonatal Facial Coding System (NFCS) were coded from separate continuous bedside video recordings; mean heart rate (mHR) was derived from digitally sampled continuous electrographic recordings. Analysis of variance (phase x gender) with Bonferroni corrections was used to compare differences in NIDCAP, NFCS, and mHR. Pearson correlations were used to examine relationships between the NIDCAP and infant background characteristics. Results. NFCS and mHR increased significantly to lance/squeeze. Eight NIDCAP behaviors also increased significantly to lance/squeeze. Another 5 NIDCAP behaviors decreased significantly to lance/squeeze. Infants who had lower GA at birth, had been sicker, had experienced more painful procedures, or had greater morphine exposure showed increased hand movements indicative of increased distress. Conclusions. Of the 85 NIDCAP behaviors, a subset of 8 NIDCAP movements were associated with pain. Particularly for infants who are born at early GAs, addition of these movements to commonly used measures may improve the accuracy of pain assessment. Pediatrics 2004;114:65-72; preterm infant, pain, NIDCAP, movement, NICU. ABBREVIATIONS. NIDCAP, Newborn Individualized Developmental Care and Assessment Program; NICU, neonatal intensive care unit; GA, gestational age; PCA, postconceptional age; NFCS, Neonatal Facial Coding System; SNAP-II, Score for Neonatal Acute Physiology II., Major advances in neonatal care now enable a high proportion of preterm infants to survive. During a time when medical concerns focused primarily on stabilizing the physiologic needs of preterm [...]

Premature babies who have bronchopulmonary dysplasia, brain injury on an ultrasound scan, or retinopathy of prematurity have a poor prognosis, according to a study of 910 very-low-birth-weight babies. Almost 90% of the babies with all three conditions had a poor prognosis at 18 months, compared with 62% of the babies with two of the conditions, 42% of the babies with one, and 18% of the babies with none. Adverse health outcomes included death, cerebral palsy, intellectual disability, deafness and blindness.

Objective. Children with neurologic impairments have shown diminished pain response compared with control subjects; however, it remains unclear what mechanisms underlie this response or when it develops. If this were also true with premature infants who undergo neonatal intensive care, then infants with parenchymal brain injury (PBI) would be at increased risk of underrecognition and undertreatment of procedural pain. The purpose of this study was to determine whether infants with PBI display altered responses to acute procedural pain at 32 weeks' postconceptional age (PCA), compared with control subjects. Methods. We compared responses to blood collection by heel lance at 32 weeks' PCA in 12 very low birth weight infants (mean [range] birth weight: 876 g [630-1240 g]; gestational age: 26.3 weeks (24-28 weeks) who had sustained PBI in the neonatal period, with 12 control subjects matched for gestational age at birth and gender (838 g [625-990 g]; 26.3 weeks [24-28 weeks]) who had normal neonatal brain imaging. PBI was defined as cerebral parenchymal infarction (grade 4 intraventricular hemorrhage) or cystic periventricular leukomalacia on serial cranial ultrasound scans conducted in the neonatal period. Biobehavioral responses to pain were measured using facial activity (Neonatal Facial Coding System) and measures of heart rate (HR) variability (low-frequency [LF] power [0.04-0.15], high-frequency [HF] power [0.15-0.8 Hz], and LF/HF ratio) as a measure of cardiac autonomic modulation. Neurodevelopmental follow-up was undertaken at 18 months. Results. The infants with PBI had significantly higher illness severity scores at day 1 compared with day 3 (Score of Neonatal Acute Physiology II: 32.1 vs 19.8) but similar previous pain experiences (109 vs 115) and total morphine exposure (0.29 vs 0.30 mg/kg). Both groups of children mounted similar responses to heel lance at 32 weeks' PCA with no difference in facial response or HR variability. Mean HR and facial action scores increased from baseline to the lance, whereas LF, HF, and the LF/HF ratio decreased significantly. No group differences were found. The only statistically significant difference between groups was that infants with PBI had more tongue protrusion at lance. Neurodevelopmental follow-up showed 8 of 11 toddlers with PBI had cerebral palsy compared with 0% of control toddlers. Psychomotor Developmental Index score on the Bayley Scales of Infant Development II was significantly lower in the PBI group. Five of 11 toddlers with PBI had Mental Developmental Index score Conclusion. Contrary to expectations, we did not find any evidence of an altered pain response pattern in infants with proven brain injury in the neonatal period. Although most infants with PBI developed cerebral palsy, these findings suggest that cerebral injury predominantly to the central white matter leaves brainstem responses intact in the neonatal period. Furthermore, it seems that the injured brain of the preterm infant has not yet expressed the identifiable differences in pain display and the functional impairment observed at later ages. Pediatrics 2002;110:570-576; preterm infants, pain reactivity, parenchymal brain injury., ABBREVIATIONS. SNI, significant neurologic impairment; IVH, intraventricular hemorrhage; PVL, periventricular leukomalacia; NICU, neonatal intensive care unit; PCA, postconceptional age; PBI, parenchymal brain injury; SNAP, Score of Neonatal Acute Physiology; NFCS, [...]

The loss of water from brain tissue results in decreased extravascular (outside of blood vessels) pressures within the brain, and may contribute to the development of bleeding within the germinal matrix and ventricles of the brain in premature infants. Blood levels of sodium reflect the hydration status, or water content, of tissue. The importance of high sodium levels and dehydration, or loss of body water, in increasing the risk of germinal matrix/intraventricular hemorrhage was assessed. Two hundred and ninety-nine premature infants weighing less than 1,500 grams (3.3 pounds) at birth were evaluated for blood levels of sodium and germinal matrix/intraventricular hemorrhage during the first four days of life. Intraventricular hemorrhage occurred in 34 of 106 infants with sodium levels of 145 millimoles per liter (mmol/L) or less, and in 54 of 193 infants with sodium levels greater than 145 mmol/L. These findings suggest that blood levels of sodium greater than 145 mmol/L do not increase the risk of germinal matrix/intraventricular hemorrhage in premature infants. Thus, giving more fluids to maintain adequate extravascular pressure within the brain will probably not affect the incidence of bleeding within the germinal matrix and ventricles of the brain. (Consumer Summary produced by Reliance Medical Information, Inc.)

Objectives. To compare aerobic capacity, strength, flexibility, and activity level in extremely low birth weight (ELBW) adolescents at 17 years of age with term-born control subjects. Methods. Fifty-three ELBW teens of birth weight [less than or equal to] 800 g were assessed at 17.3 years (16.3-19.7 years; birth weight: 720 g [520-800 g]; gestation: 26 weeks [23-29 weeks]) along with term-born control subjects (n = 31) at age 17.8 years (16.5-19.0 years; birth weight: 3506 g [3068-4196 gl; gestation: weeks 40 [39-42 weeks]). ELBW and control teens were assessed by a pediatric physiotherapist and completed components of the Canadian Physical Activity, Fitness and Lifestyle Appraisal and a self-assessment fitness and activity questionnaire. Continuous data were analyzed using MANOVA (group, gender) followed by t tests; categorical data were analyzed using the [chi square] test. Results. ELBW teens had lower aerobic capacity, grip strength, leg power, and vertical jump; could do fewer push-ups; had less abdominal strength as measured by cuff-ups; had less lower back flexibility; and had tighter hamstrings. ELBW teens reported less previous and current sports participation, lower physical activity level, and poorer coordination compared with term-born control subjects. ELBW teens were also found to have more difficulty with maintenance of rhythm and cadence. Although ELBW teens rated themselves lower on all measures of sporting activity, they were as happy with their level of fitness as the control subjects. Conclusions. Compared with term-born control subjects, there are significant differences in motor performance in unimpaired ELBW survivors in late adolescence, reflected in aerobic capacity, strength, endurance, flexibility, and activity level. We conclude that these differences in fitness and physical activity are related to the interaction of effects of premature birth on the motor system together with a more inactive lifestyle. These findings have potential implications for later adult health problems. URL: www.pediatrics.org/cgi/doi/10.1542/peds.2004-1603; premature infants, extremely low birth weight infants, follow-up studies, motor development, strength, flexibility.

Objective. To compare academic and cognitive ability, attention, attitudes, and behavior of extremely low birth weight (ELBW) adolescents who are free of major impairments at 17 years of age with [...]

Objectives. Stress systems may be altered in the long term in preterm infants for multiple reasons, including early exposure to procedural pain in neonatal intensive care. This question has received little attention beyond hospital discharge. Stress responses (cortisol) to visual novelty in preterm infants who were born at extremely low gestational age (ELGA; [less than or equal to] 28 weeks), very low gestational age (VLGA; 29-32 weeks), and term were compared at 8 months of age corrected for prematurity (corrected chronological age [CCA]). In addition, among the preterm infants, we evaluated whether cortisol levels at 8 months were related to neonatal exposure to procedural pain and morphine in the neonatal intensive care unit. Methods. Seventy-six infants, 54 preterm ([less than or equal to] 32 weeks' GA at birth) and 22 term-born infants who were seen at 8 months CCA composed the study sample, after excluding those with major sensory, motor, or cognitive impairment. Salivary cortisol was measured before (basal) and 20 minutes after introduction of novel toys (post 1) and after developmental assessment (post 2). Results. Salivary cortisol was significantly higher in ELGA infants at 8 months, compared with the VLGA and term groups before and after introduction of visual novelty. Term-born and VLGA infants showed a slight decrease in cortisol when playing with novel toys, whereas the ELGA group showed higher basal and sustained levels of cortisol. After controlling for early illness severity and duration of supplemental oxygen, higher basal cortisol levels in preterm infants at 8 months' CCA were associated with higher number of neonatal skin-breaking procedures. In contrast, cortisol responses to novelty were predicted equally well by neonatal pain or GA at birth. No relationship between morphine dosing and cortisol response was demonstrated in these infants. Conclusions. ELGA preterm infants show a different pattern of cortisol levels before and after positive stimulation of visual novelty than more maturely born, VLGA preterm and term-born infants. Exposure to high numbers of skin-breaking procedures may contribute to "resetting" basal arousal systems in preterm infants. Pediatrics 2004;114:e77-e84. URL: http://www.pediatrics. org/cgi/content/full/114/1/e77; pain, stress, premature infants, novelty, cortisol, morphine.