Use of the Bayley Infant Neurodevelopmental Screener with low birth weight infants.

OBJECTIVE: To examine the utility of the Bayley Infant Neurodevelopmental Screener (BINS) as a screening technique for premature, low birth weight infants. METHODS: One hundred thirty-three preterm infants <1,500 grams received a BINS assessment at mean adjusted age 6.8 months and a Bayley Scales of Infant Development, Second Edition (BSID-II) assessment at mean adjusted age 12.9 months. Infants' BINS scores were compared to their BSID-II Mental Development Index (MDI) and Psychomotor Development Index (PDI) scores. RESULTS: The BINS score showed significant association with the MDI (r =.40, p = <.001) and with the PDI (r =.35, p = <.001). The BINS showed moderate predictive validity (67%-76%) for identifying lower functioning infants. CONCLUSIONS: The BINS is a satisfactory screening tool for low birth weight infants when used in conjunction with other known biologic and social risk factors.

A critical review of cranial ultrasounds: is there a closer association between intraventricular blood, white matter abnormalities or cysts, and cerebral palsy?

In an attempt to determine cranial ultrasonographic features of preterm infants with intraventricular hemorrhage (IVH) 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 IVH 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.

Neurodevelopmental outcome of prematurely born children treated with recombinant human erythropoietin in infancy.

OBJECTIVE: To compare the neurodevelopmental outcome of premature infants treated with recombinant human erythropoietin with that of control infants. STUDY DESIGN: A total of 20 treated infants and 20 control infants who had completed randomized, double-blind, placebo-controlled studies of recombinant human erythropoietin as treatment for anemia of prematurity were followed for growth and developmental outcome in an intensive care nursery follow-up program. Infants were assessed by standard developmental tests. RESULTS: No differences were found between groups for neurologic outcome, cognitive outcome, or growth patterns. All infants treated with recombinant human erythropoietin were neurologically normal. The rate of cognitive deficits was similar in the two groups. CONCLUSION: In this small sample we did not see differences in neurodevelopmental outcome between infants treated with recombinant human erythropoietin and control infants.

A new pattern of cerebellar hemorrhages in preterm infants.

OBJECTIVE: Posterior fossa hemorrhages may be underdiagnosed in surviving neonates, with cerebellar hemorrhage discovered in 10% to 25% of autopsy specimens from very low birth weight infants. Posterior fossa lesions have been difficult to visualize by the traditional ultrasonography approach through the anterior fontanelle. Late in 1994, routine posterior fossa imaging through the posterolateral fontanelle was instituted to improve the ultrasonographic visualization of the posterior fossa in neonates. METHODS: Infants identified with posterior fossa hemorrhage by cranial ultrasonography between 1994 and 1996 were followed prospectively through discharge and their clinical courses reviewed. Infants diagnosed with posterior fossa hemorrhage between 1991 and 1994 were identified retrospectively from a comprehensive radiology database to use in comparison. All infants surviving to discharge were entered into neurodevelopmental follow-up using standard developmental assessments. RESULTS: Approximately 525 infants underwent cranial sonography during the study period between October 1994 and September 1996, including 250 infants weighing <1500 g. Thirteen infants were identified with posterior fossa hemorrhage using the posterolateral fontanellar approach. In contrast, only 2 infants were identified with posterior fossa hemorrhage between 1991 and 1994 using traditional anterior fontanellar views. Six very low birth weight infants were identified with cerebellar hemorrhages not associated with supratentorial, intraventricular hemorrhage. Each hemorrhage had a clinically silent presentation and, in 5 infants, was not well-appreciated by anterior fontanellar images. Magnetic resonance imaging studies were performed on 5 of the 6 infants and confirmed a cerebellar lesion in the area of previous echo density on ultrasonography. No infant is exhibiting motor abnormalities on neurologic examination, although 4 infants are demonstrating cognitive, developmental delay. Follow-up, however, is limited to a corrected age of

Infants with birth weight 1,000-1,499 grams born in three time periods: has outcome changed over time?

The objective of this study was to see whether outcome of infants of larger birth weight (1,000-1,499 grams) has changed with advances in neonatology. The outcome of infants born in a recent time period (1989-1991) was compared with that of infants born previously, in 1984-1986 and 1979-1981. Univariate analyses were conducted on the association of medical risk factors and date of birth with outcome. More than 90% of infants in each time period were neurologically normal and more than 80% were cognitively normal. Predictor variables were intracranial hemorrhage for poor neurologic outcome and days on oxygen for poor cognitive outcome. We found that neurodevelopmental outcome was stable over three time periods.

Neurodevelopmental outcome after open fetal surgery.

PURPOSE: This study examined the neurological and age-appropriate developmental outcomes of 11 children who underwent open fetal surgery. RESULTS: Nine children have normal neurological outcomes, and nine have normal development. CONCLUSION: Intensive postnatal care, intracranial hemorrhage, and requirement for prolonged respiratory support were associated with a worse neurological and developmental prognosis.

Risk factors associated with infant death among very low birth weight infants after discharge from an intensive care nursery.

Low birth weight infants have an increased incidence of death after discharge from the intensive care nursery (ICN). To evaluate factors associated with death, and especially unexpected death, we conducted a study on 724 infants discharged from our ICN with a birth weight 1500 g or less. Twenty-four infants died during the 1st year after discharge. Univariate analyses and logistic regression analyses were used to examine the effects of birth weight, gestational age, race, gender, growth retardation, chronic lung disease (CLD), intracranial hemorrhage (ICH), and socioeconomic risk on postdischarge death. Of the risk factors studied, only CLD (p = .001) and ICH (p = .004) were independently associated with death, but ICH alone was the most worrisome risk factor associated with sudden, unexpected death in low birth weight infants after discharge from an ICN.

Outcome of infants born at 24-26 weeks' gestation: II. Neurodevelopmental outcome.

OBJECTIVE: To assess the neurodevelopmental outcome of infants born at 24-26 weeks' gestation. METHODS: One hundred thirty-eight nonanomalous infants were born at our hospital after pregnancies of 24-26 weeks' gestation between 1990 and 1994. Ninety-four infants survived to discharge and 86 were followed in a nursery follow-up program for outcome. Associations between gestational age and neurodevelopmental outcome and risk factors and outcome were analyzed. Mean age at follow-up was 32 months. RESULTS: The frequency of cerebral palsy did not differ significantly in the three groups (11, 20, and 11% at 24, 25, and 26 weeks, respectively). The incidence of normal cognitive outcome was associated significantly with gestational age at birth (28, 47, and 71% normal at 24, 25, and 26 weeks, respectively). Poor neurologic outcome was associated with the medical risk factor of intracranial hemorrhage grade 3 or 4 or periventricular leukomalacia. Poor cognitive outcome was correlated with both medical and social risk factors; however, there was an association between poor cognitive outcome and lower gestational age (P < .05), regardless of the relationships of any other risk factors to cognitive outcome. CONCLUSION: Although the incidence of cerebral palsy was low in these three groups, the high percentage of infants born at 24 and 25 weeks' gestation with cognitive deficits is concerning.

Outcome of extremely low birth weight infants (500 to 999 grams) over a 12-year period.

OBJECTIVE: Advances in neonatology have contributed to improved survival for extremely low birth weight (ELBW) infants. Neurodevelopmental outcome is usually reported for a single large group of infants rather than according to smaller birth weight groups because of small numbers. Our purpose was to review the neurodevelopmental outcome of a large group of ELBW infants and examine differential outcome according to birth weight. STUDY DESIGN: A total of 446 infants born between 1979 and 1991, with a birth weight of 500 to 999 g, were followed to mean age 55 months +/- 33 standard deviation. Univariate analyses of medical risk factors of birth weight, gestational age, year of birth, growth retardation, gender, inborn/outborn status, days on oxygen, intracranial hemorrhage, and social risk in relation to outcome were conducted on the group as a whole. Neurologic/developmental outcome was also analyzed by 100-g weight groups. RESULTS: A total of 61% of all infants were completely normal, with no neurologic, neurosensory, or cognitive deficits. There was no association between outcome and birth weight. There was a strong association between intracranial hemorrhage (ICH) grade III or IV and/or cystic periventricular leukomalacia (PVL) and abnormal outcome (Somers' D = .17) and ICH III/IV and/or cystic PVL and cognitive outcome (Kendall's tau = .15). Mild to moderate cognitive delays were associated with chronic lung disease (oxygen >60 days) (Kruskal-Wallis chi2 = 17.53) or high social risk (Kruskal-Wallis chi2 = 22.17). CONCLUSION: In this study of ELBW infants, low birth weight was not associated with abnormal outcome. The risk factors of ICH III-IV/cystic PVL, chronic lung disease, and high social risk were associated with abnormal outcome.

School age outcome in low birth weight preterm infants.

Very low birth weight (VLBW) children at school age show variability in their outcome, compared with normal birth weight children, although many early physical and health differences are equalized by middle childhood. Studies of nonhandicapped VLBW children have found a higher rate of school retention and school problems in this population. Differences in intelligence have been reported, although these are often confounded by socioeconomic factors such as educational level of the parent. Few studies today of children born in the late 1970s and early 1980s have related school age outcome to central nervous system (CNS) status, yet for learning disabilities or other neuropsychological deficits, this may be highly relevant. Better understanding of medical risk factors, however, will not affect the decisive influence of social factors on their expression in the school age child.

Outcome of very low birth weight infants: multiple gestation versus singletons.

OBJECTIVE: Multiple gestation infants are overrepresented in intensive care nurseries, and have been reported to have greater morbidity than singletons. A cohort of very low birth weight infants was examined to determine outcome of premature infants based on gestation type (multiple or single) and hypothesized that at this low birth weight, the outcome of the groups would be similar. METHOD: The sample was composed of all infants with birth weights < or = 1250 g born in a 10-year period (September 1977 through September 1987). Ninety-two percent (n = 364) of the infants discharged were seen at 1 year of age, and 73% (n = 249) were observed to school age. Morbidity was assessed by neurodevelopmental examinations and standard developmental tests. RESULTS: At 1 year of age and at school age, there were no differences in neurologic or neurosensory outcome between multiple gestation and single gestation infants. Logistic regression analyses were performed on the school age data, using cognitive outcome as the dependent variable and gestation type, birth weight, gestational age, intracranial hemorrhage, chronic lung disease, and a social risk factor as predictor variables. Gestation type was not associated with cognitive outcome at school age. Social risk factors and chronic lung disease showed an association with cognitive outcome at school age. CONCLUSIONS: Multiple gestation was not related to increased morbidity in this very low birth weight group. The developmental outcome of all infants with birth weights < or = 1250 g in this study was related to medical and social risk factors. These findings were consistent for a large group of infants over a 10-year period.

Selected indications for and applications of magnetic resonance angiography in children.

The purpose of this study was to investigate the efficacy and practicality of magnetic resonance angiography (MRA) in evaluating pediatric cerebrovascular disorders. A retrospective evaluation was performed of MR angiograms in 20 pediatric patients with cerebrovascular pathology. When appropriate, comparisons were made with duplex ultrasonography or conventional catheter angiography. MRA accurately assessed the patency of carotid reanastomoses in 8 babies who had previously undergone extracorporeal membrane oxygenation (ECMO). In 6 patients with moyamoya syndrome, MRA accurately evaluated stenotic intracranial carotid and circle of Willis arteries and progressive enlargement of the superficial temporal and middle cerebral arteries after revascularization procedures, and thus obviated the need for sequential angiograms. Thrombi and emboli were identified in 4 of 5 patients with symptoms and imaging evidence of an acute stroke. Two-dimensional time-of-flight MR venograms, acquired in both axial and coronal planes, were useful for preoperative venous mapping in a patient with an occipital encephalocele and detecting venoocclusive disease. MRA provided diagnostically useful information in a spectrum of pediatric cerebrovascular disorders. It can be used as the initial vascular imaging modality for patients with imaging evidence of acute cerebrovascular event, to evaluate progression of chronic vasoocclusive disease, to evaluate vessel patency following intracranial revascularization surgery, and for visualization of the venous circulation.

Effect of medical and social risk factors on outcome of prematurity and very low birth weight.

A cohort of 129 infants with birth weights less than or equal to 1250 gm was followed for more than 4 1/2 years (mean +/- SD: 60 +/- 10 months) to determine the independent effects of two medical risk factors--intracranial hemorrhage and severe chronic lung disease--and a parenting risk factor (abuse or neglect) on neurodevelopmental outcome. In infants without any intracranial hemorrhage or parenting risk factors, severe chronic lung disease was not related to neurologic or cognitive outcome. Infants with increasing grades of intracranial hemorrhage had increasing rates of neurologic and cognitive abnormalities. However, the factor associated with the highest incidence of later abnormality was the parenting risk factor. We conclude that infants with medical risk factors may have additional social risk factors, and that both of these influences must be considered in an examination of the long-term sequelae of neonatal complications.

Videophone use improves maternal interest in transported infants.

A telephone video transmission unit was utilized to assist in the attachment of mothers to their transported sick infants. To evaluate its effectiveness, the number of telephone calls to the ICN made by the mothers using the unit was used as a variable to "quantify" interest in their newborns; this was compared with the number of calls made by a matched group of mothers who did not utilize the videophone. There was a significantly larger number of calls made by the study mothers both while hospitalized and after discharge when they no longer had use of the videophone. Use of the unit appeared to alleviate some maternal anxieties and encouraged early endearment by the study mothers. How this affects the long-term relationship between infant and mother will require further follow-up investigation.