Meconium "aspiration" (or respiratory distress associated with meconium-stained amniotic fluid?).

The designation meconium aspiration syndrome (MAS) reflects a spectrum of disorders in infants born with meconium-stained amniotic fluid, ranging from mild tachypnea to severe respiratory distress and significant mortality. The frequency of MAS is highest among infants with post-term gestation, thick meconium, and birth asphyxia. Pulmonary hypertension is an important component in severe cases. Prenatal hypopharyngeal suctioning and postnatal endotracheal intubation and suctioning of vigorous infants are not effective. Intubation and suctioning of non-breathing infants is controversial and needs more investigation. Oxygen, mechanical ventilation, and inhaled nitric oxide are the mainstays of treatment. Surfactant is often used in infants with severe parenchymal involvement. High-frequency ventilation and extracorporeal membrane oxygenation are usually considered rescue therapies.

Neuropsychological Functioning in Preterm-Born Twins and Singletons at Preschool Age.

OBJECTIVES: A limited body of research is available on the relationships between multiplicity of birth and neuropsychological functioning in preterm children who were conceived in the age of assisted reproductive technology and served by the modern neonatal intensive care unit. Our chief objective was to evaluate whether, after adjustment for sociodemographic factors and perinatal complications, twin birth accounted for a unique portion of developmental outcome variance in children born at-risk in the surfactant era. METHODS: We compared the neuropsychological functioning of 77 twins and 144 singletons born preterm (<34 gestational weeks) and served by William Beaumont Hospital, Royal Oak, MI. Children were evaluated at preschool age, using standardized tests of memory, language, perceptual, and motor abilities. RESULTS: Multiple regression analyses, adjusting for sociodemographic and perinatal variables, revealed no differences on memory or motor indices between preterm twins and their singleton counterparts. In contrast, performance of language and visual processing tasks was significantly lower in twins despite reduced perinatal risk in comparison to singletons. Effect sizes ranged from .33 to .38 standard deviations for global language and visual processing ability indices, respectively. No significant group by sex interactions were observed, and comparison of first-, or second-born twins with singletons yielded medium effect sizes (Cohen's d=.56 and .40, respectively). CONCLUSIONS: The modest twin disadvantage on language and visual processing tasks at preschool-age could not be readily attributable to socioeconomic or perinatal variables. The possibility of biological or social twinning-related phenomena as mechanisms underlying the observed performance gaps are discussed. (JINS, 2016, 22, 865-877).

Physical growth in the neonatal intensive-care unit and neuropsychological performance at preschool age in very preterm-born singletons.

We studied the associations between early postnatal growth gains and neuropsychological outcome in very preterm-born children. Specifically, we wished to establish whether relationships exist between gains in head circumference (relative to gains in body-weight or length), from birth to hospital discharge, and intellectual, language, or motor, performance at preschool age. We used data from 127 preschoolers, born <33 weeks, all graduates of the William Beaumont Hospital Neonatal Intensive-Care Unit (NICU) in Royal Oak, MI. Cognitive, motor, and language outcomes were evaluated using the Wechsler Preschool and Primary Scales of Intelligence-Revised, Peabody Developmental Scales - 2(nd) Edition, and the Preschool Language Scale - 3(rd) Edition, respectively. Differences between Z-scores at birth and hospital discharge, calculated for three anthropometric measures (head circumference, weight, length), were variables of interest in separate simultaneous multiple regression procedures. We statistically adjusted for sex, socioeconomic status, birth weight, length of hospitalization, perinatal complications, and intrauterine growth. Examination of the relationships between anthropometric indices and outcome measures revealed a significant association between NICU head growth and global intelligence, with the Z-difference score for head circumference accounting for a unique portion of the variance in global intelligence (ηp(2) =.04). Early postnatal head growth is significantly associated with neuropsychological outcome in very preterm-born preschoolers. To conclude, despite its relative brevity, NICU stay, often overlapping with the end of 2(nd) and with the 3(rd) trimester of pregnancy, appears to be a sensitive developmental period for brain substrates underlying neuropsychological functions.

Early blood gas predictors of bronchopulmonary dysplasia in extremely low gestational age newborns.

Aim. To determine among infants born before the 28th week of gestation to what extent blood gas abnormalities during the first three postnatal days provide information about the risk of bronchopulmonary dysplasia (BPD). Methods. We studied the association of extreme quartiles of blood gas measurements (hypoxemia, hyperoxemia, hypocapnea, and hypercapnea) in the first three postnatal days, with bronchopulmonary dysplasia, among 906 newborns, using multivariable models adjusting for potential confounders. We approximated NIH criteria by classifying severity of BPD on the basis of the receipt of any O2 on postnatal day 28 and at 36 weeks PMA and assisted ventilation. Results. In models that did not adjust for ventilation, hypoxemia was associated with increased risk of severe BPD and very severe BPD, while infants who had hypercapnea were at increased risk of very severe BPD only. In contrast, infants who had hypocapnea were at reduced risk of severe BPD. Including ventilation for 14 or more days eliminated the associations with hypoxemia and with hypercapnea and made the decreased risk of very severe BPD statistically significant. Conclusions. Among ELGANs, recurrent/persistent blood gas abnormalities in the first three postnatal days convey information about the risk of severe and very severe BPD.

Postnatal growth and neuropsychological performance in preterm-birth preschoolers.

OBJECTIVE: Compromised postnatal growth is an important risk factor accounting for poorer neuropsychological performance of preterm children during the preschool years, yet its unique contribution to explaining outcome variance within this high risk group has yet to be determined. Therefore, we examined within a large preterm sample (1) the relationships between head growth, measured either at birth or preschool age, and outcome; (2) the relationships of binary versus dimensional head growth measures and performance; and (3) the unique contribution of preschool-age head growth, after adjustment for general physical development (indexed by stature), to variance in neuropsychological functioning. METHOD: We evaluated 264 preterm (<36 weeks) preschoolers, without severe handicaps, using cognitive, language, and motor skill measures. Multiple regression analyses, adjusting for sociodemographic factors and pre-, peri-, and postnatal confounds, were used to study associations between growth indices and performance. RESULTS: While suboptimal head growth classification at birth was significantly associated only with motor performance, suboptimal head growth at preschool age explained a significant portion of variance in intellectual and language measures (g = .46 to .60). Treating preschool head size as a continuous dimension yielded null results, however, with body-height explaining a significant portion of the variance across several domains. CONCLUSION: Among postnatal anthropometric indices, preschool stature, rather than head circumference, remains a consistent correlate of preschool outcome in preterm children, highlighting the contribution of general physical development to neuropsychological performance. Further investigation of the underlying mechanisms likely involves exploration of complex relationships between postnatal nutrition, growth hormone levels, body and brain development, and neuropsychological functioning.

Early postnatal hypotension and developmental delay at 24 months of age among extremely low gestational age newborns.

OBJECTIVES: To evaluate in extremely low gestational age newborns, relationships between indicators of hypotension during the first 24 postnatal hours and developmental delay at 24 months of age. METHODS: The 945 infants in this prospective study were born at <28 weeks, were assessed for three indicators of hypotension in the first 24 postnatal hours, and were evaluated with the Bayley Mental Development Index (MDI) and Psychomotor Development Index (PDI) at 24 months corrected age. Indicators of hypotension included: (1) mean arterial pressure in the lowest quartile for gestational age; (2) treatment with a vasopressor; and (3) blood pressure lability, defined as the upper quartile for the difference between the lowest and highest mean arterial pressure. Logistic regression was used to evaluate relationships between hypotension and developmental outcomes, adjusting for potential confounders. RESULTS: 78% of infants in this cohort received volume expansion or vasopressor; all who received a vasopressor were treated with volume expansion. 26% had an MDI <70 and 32% had a PDI <70. Low MDI and PDI were associated with low gestational age, which in turn, was associated with receipt of vasopressor treatment. Blood pressure in the lowest quartile for gestational age was associated with vasopressor treatment and labile blood pressure. After adjusting for potential confounders, none of the indicators of hypotension were associated with MDI <70 or PDI <70. CONCLUSIONS: In this large cohort of extremely low gestational age newborns, we found little evidence that early postnatal hypotension indicators are associated with developmental delay at 24 months corrected gestational age.

One hundred consecutive infants born at 23 weeks and resuscitated.

We sought to delineate the in-hospital outcome for infants born alive and universally resuscitated at an estimated gestational age (GA) of 23(0)/(7) to 23(6)/(7) weeks and to document when and why death occurred. We performed a cohort study of prospectively collected data on 100 consecutive infants born alive at 23 weeks GA from June 16, 1990 through August 6, 2006. All deliveries were attended by a neonatologist and resuscitation was universally attempted. At the time of death, a primary cause was determined by the attending neonatologist. Forty infants survived and 60 died prior to hospital discharge. Survivors were more likely to have higher Apgar scores and be male gender. Ten infants could not be resuscitated and died in the delivery room. Twenty-eight other infants died in the first 4 days mainly from respiratory failure (10 from respiratory distress syndrome [RDS], 12 from RDS with interstitial emphysema, 5 from RDS with pulmonary hemorrhage). Twenty-two infants died after day 4 (8 from respiratory failure, 10 from necrotizing enterocolitis, and 4 from sepsis). In our experience, universal resuscitation at 23 weeks' estimated GA resulted in a survival rate of 40%.

Clinical report--Antenatal counseling regarding resuscitation at an extremely low gestational age.

The anticipated delivery of an extremely low gestational age infant raises difficult questions for all involved, including whether to initiate resuscitation after delivery. Each institution caring for women at risk of delivering extremely preterm infants should provide comprehensive and consistent guidelines for antenatal counseling. Parents should be provided the most accurate prognosis possible on the basis of all the factors known to affect outcome for a particular case. Although it is not feasible to have specific criteria for when the initiation of resuscitation should or should not be offered, the following general guidelines are suggested. If the physicians involved believe there is no chance for survival, resuscitation is not indicated and should not be initiated. When a good outcome is considered very unlikely, the parents should be given the choice of whether resuscitation should be initiated, and clinicians should respect their preference. Finally, if a good outcome is considered reasonably likely, clinicians should initiate resuscitation and, together with the parents, continually reevaluate whether intensive care should be continued. Whenever resuscitation is considered an option, a qualified individual, preferably a neonatologist, should be involved and should be present in the delivery room to manage this complex situation. Comfort care should be provided for all infants for whom resuscitation is not initiated or is not successful.

Prevention and management of pain in the neonate: an update.

The prevention of pain in neonates should be the goal of all caregivers, because repeated painful exposures have the potential for deleterious consequences. Neonates at greatest risk of neurodevelopmental impairment as a result of preterm birth (ie, the smallest and sickest) are also those most likely to be exposed to the greatest number of painful stimuli in the NICU. Although there are major gaps in our knowledge regarding the most effective way to prevent and relieve pain in neonates, proven and safe therapies are currently underused for routine minor yet painful procedures. Every health care facility caring for neonates should implement an effective pain-prevention program, which includes strategies for routinely assessing pain, minimizing the number of painful procedures performed, effectively using pharmacologic and nonpharmacologic therapies for the prevention of pain associated with routine minor procedures, and eliminating pain associated with surgery and other major procedures.

Unexpected versus anticipated cystic periventricular leukomalacia.

The objective of this study is to contrast the clinical profile of premature infants who develop cystic periventricular leukomalacia (cPVL) following a severe hemodynamic event (anticipated) with infants whose cPVL is not preceded by such an event (unexpected). The study design is a Retrospective Cohort. The study setting is a Neonatal Intensive Care Unit. Infants born at a gestational age of 23-32 weeks received serial cranial ultrasounds to screen for cPVL. Infants were divided into two groups based upon whether or not they had experienced a hemodynamic event of sufficient severity to potentially cause cPVL. Details of the clinical profile of these two groups were compared. Cystic PVL occurred in 27 infants (2.1%). In 15 infants (56%) cPVL was antipicated as there was at least one severe preceding hemodynamic event. Twelve infants (44%) had not experienced such an event and the discovery of cPVL on routine cranial ultrasound was unexpected. These infants were more likely to have been born to mothers who had received tocolytics (67 versus 13%, p = 0.004), prenatal steroids (67 vs. 27%, p = 0.038), and intrapartum antibiotics (92 vs. 20%, p < 0.001) and were more likely to have been delivered more than 6 hours after arrival to the hospital (83 vs. 40%; p = 0.038) than infants whose cPVL was anticipated. The diagnosis of clinical chorioamnionitis was also more common in the group of infants whose cPVL was unexpected (50 vs. 13%, p = 0.038). Almost half (44%) of our cases of cPVL occurred unexpectedly in infants who did not appear to have an obvious cause, as they had not experienced a severe hemodynamic event. These infants were more commonly delivered to mothers who had been hospitalized long enough to have received a variety of prenatal therapies and more often had a diagnosis of chorioamnionitis.