[More cot deaths in child care settings than during the same hours at home: 10-year statistics]. / Meer wiegendood tijdens kinderopvang dan in dezelfde uren thuis: 10-jaarscijfers.

OBJECTIVE: To determine whether the incidence of sudden infant death syndrome (SIDS) in child care settings (child care centres or child minders) is different from that in the home setting, and to search for any differences in the prevalence of SIDS risk factors in both settings. DESIGN: Descriptive and comparative. METHOD: All SIDS cases (< 2 years), that occurred between September 1996-August 2006 and known to the 'Landelijke Werkgroep Wiegendood' (the National Cot Death Study Group) of the Dutch Paediatric Association were analysed. The percentage of children involved in child care and the mean duration of their participation in child care, was calculated from national surveys carried out in well-baby clinics. RESULTS: In the 10 years of the study, 216 cases of SIDS became known to the Cot Death Study Group. In the first year of life, the number was 75% of the number registered by Statistics Netherlands. 28 of these infants died from SIDS between the ages of 3-6 months and on Monday-Friday between 8:00 am-5:00 pm: the usual hours of opening of child care facilities. Based on the uptake of child care during this period, 15% of this mortality was expected to have occurred in a child care setting and 85% at home. In reality, 61% (17/28) of the deaths occurred at a child care facility and 39% (11/28) at home. The relative risk was 8.8 (95% CI: 4.1-19.0). This high incidence of SIDS in a child care setting did not appear to be due to a higher prevalence of known risk factors for SIDS at child care facilities i.e. sleeping position (prone or side), passive smoking, heat congestion, or use of a quilt or pillow. CONCLUSION: For infants aged 3-6 months, the relative risk ofSIDS during child care appeared to be increased 8.8 times (95% CI: 4.1-19.0) when compared with home settings in The Netherlands in September 1996-August 2006.

[Revised guideline 'prevention of cot death']. / Herziene richtlijn 'preventie wiegendood'.

There are new insights into the pathogenesis of cot death ('sudden infant death syndrome'; SIDS). Based on these new insights, the Dutch Paediatric Association and the Dutch Child and Youth Health Care Physicians have drawn up a new guideline 'Prevention of cot death', which replaces the consensus statement of 1996. The 2 major differences from the old guideline are that co-sleeping of young infants in the same bed with the parents is now actively discouraged under the age of 4 months, and that the supine sleeping position is recommended from birth on. The recommendation that lying on one side can be used during the first 2 weeks of life has now been withdrawn.

Mortality in very preterm and very low birth weight infants according to place of birth and level of care: results of a national collaborative survey of preterm and very low birth weight infants in The Netherlands.

As part of a collaborative project in the Netherlands in 1983, for which data were collected on 1,338 newborn infants (less than 32 weeks' gestation and/or less than 1,500 g birth weight), all infants were assigned to one of three levels of care according to hospital of birth. Considerable centralization was achieved by antenatal and neonatal transport. Although the uncorrected mortality rates were similar, the mortality odds (adjusted for four and 22 potential confounding perinatal factors, respectively) were significantly higher in level 1 and level 2 hospitals compared with level 3 hospitals (tertiary perinatal care centers). By extending the facilities for full perinatal intensive care in level 3 centers and thus providing optimal care for all such infants, the overall mortality rate is expected to decrease further.

Cerebral blood flow velocity changes in preterm infants after a single dose of indomethacin: duration of its effect.

Indomethacin decreases cerebral blood flow velocity and blood flow in the preterm infant. The duration of this negative effect has not been established. Cerebral blood flow velocity was evaluated in 24 preterm infants with symptomatic patent ductus arteriosus before and during the first 12 hours after a single intravenous dose of indomethacin, 0.1 mg/kg. Cerebral blood flow velocity was estimated by serial Doppler investigations of the anterior cerebral arteries. Indomethacin administration led to an instantaneous decrease of peak systolic flow velocity, temporal mean flow velocity, and end-diastolic flow velocity of the anterior cerebral arteries in all infants, which was maximal between 2 and 40 minutes after indomethacin administration and was followed by a more sustained recovery of all velocities to baseline values. Temporal mean flow velocity was not different from pre-indomethacin values at 3 hours after the administration. It is concluded that indomethacin can impact the cerebral circulation of the preterm infant for at least 2 hours. This may have consequences in preterm infants with unstable hemodynamics and pulmonary function.

Hyperbilirubinemia in preterm infants and neurodevelopmental outcome at 2 years of age: results of a national collaborative survey.

As part of a prospective national survey of preterm and small for gestational age infants in the Netherlands, the relationship between maximal serum total bilirubin concentration in the neonatal period and neurodevelopmental outcome at the corrected age of 2 years was studied. Initially, 1,338 infants with a gestational age of less than 32 completed weeks and/or a birth weight of less than 1,500 g were enrolled in the study; 146 were subsequently excluded because of congenital malformations and 361 died during the study period. At the corrected age of 2 years, 831 children were available for follow-up. Children with minor and major handicaps had significantly greater maximal serum total bilirubin concentrations than children with a normal neurodevelopmental outcome (P = .02). A consistent increase in prevalence of handicaps was found for each 50-mumol/L (2.9 mg/dL) increase of maximal serum total bilirubin concentration. The handicaps consisted mainly of cerebral palsy. Logistic regression analysis involving seven suspected confounding factors (gestational age, birth weight, seizures, intracranial hemorrhage, respiratory distress syndrome, ventriculomegaly, and bronchopulmonary dysplasia) revealed that the odds ratio was 1.3. This indicates that, on a multiplicative scale, the risk of a handicap increased by 30% for each 50-mumol/L (2.9 mg/dL) increase of maximal serum total bilirubin concentration (P = .02). Further analysis treated bilirubin as a categorized exposure. A striking systematic increase was found, suggesting a causal relationship between maximal serum total bilirubin concentration and neurodevelopmental outcome.

Sex difference in disability and handicap at five years of age in children born at very short gestation.

OBJECTIVE: The objective of this study was to examine the relationship between sex and disabilities or handicaps at 5 years of age in infants born at less than 32 weeks gestation. DESIGN: From the nationwide collaborative survey starting in 1983, including perinatal data obtained during routine perinatal care and follow-up assessments by the attending pediatricians, data from 1008 infants fulfilling the criteria were used. At age 5 years, a detailed assessment was performed by three specially trained pediatricians in 96% surviving infants (n = 648), of which 345 were boys. Each child was categorized as disabled or handicapped, using World Health Organization definitions. RESULTS: The prevalence of handicaps was three times greater in boys than in girls (21% vs 7%, odds ratio 3.2). Adjustment for gestational age and birth weight (logistic regression analysis) did not change this (odds ratio 3.5). Further adjustment by including perinatal variables such as idiopathic respiratory distress syndrome did not alter the odds ratios. The male excess in handicaps was not related to lower mortality, and therefore was not a mere consequence of a higher survival rate. The excess in handicaps was found in all assessed areas. CONCLUSIONS: Infants' sex seems to be an important determinant of handicaps. The perinatal variables used in the present study do not explain the difference in handicaps. These findings emphasize the need to include the sex distribution of a study population more systematically in analyses in future studies concerning long-term outcome of very preterm birth or low birth weight.

Maternal and neonatal transport: results of a national collaborative survey of preterm and very low birth weight infants in The Netherlands.

In a Dutch national collaborative study on 1338 infants, born in 1983 after a pregnancy of less than 32 weeks and/or with a birth weight of less than 1500 g, a comparison was made between maternal transport to university hospital perinatal centers and delivery in local or regional general hospitals and between neonatal transport to university hospital neonatal centers and treatment in local or regional general hospitals. The risk of mortality was investigated by means of logistic regression analysis including 27 perinatal risk factors as confounding variables. The results showed that infants born after maternal transport to centers had a significantly lower mortality risk. Infants treated in centers after neonatal transport had a lower mortality risk as well, but this was not statistically significant at a .05 level. The results of the study confirm that referral by maternal transport to level III centers offers the best prospects for high-risk preterm infants.

Comparison of mortality and rates of cerebral palsy in two populations of very low birthweight infants.

Comparisons of mortality and rates of cerebral palsy in different populations can be confusing. This is illustrated by comparing two populations of very low birthweight infants born in the 1980s, one from the Netherlands, the other from the UK (Oxford region). Although a number of biases were controlled for while comparing two large geographically defined populations, by assessing the survivors at similar ages and describing their health status in a standard way, some problems in interpretation of outcome remained. Differences in registration practice of live births at early gestational ages, as well as differences in withholding or withdrawing treatment, which occurred in about half of the cases of neonatal death in the Netherlands and in about one third of those in the Oxford region, may have influenced the incidence of registered live births, neonatal mortality, and the rate of cerebral palsy.

Early metabolic response to high energy shock waves in a human tumor kidney xenograft monitored by 31P magnetic resonance spectroscopy.

The effects of electromagnetically generated high-energy shock waves (HESW, Siemens Lithostar) on the phosphate metabolite levels of the NU-1 human kidney cancer xenograft implanted under the skin of the hind limb of nude mice were monitored by 31P magnetic resonance spectroscopy (MRS). Administration of 200 and 800 HESW (18.1 kV, P(+) = 37.5 MPa, P(-) = 5.2 MPa, tr = 30-120 nsec, tw = 340 nsec, freq. = 1.25 Hz), focused on the tumor centre, resulted in an immediate tumor decline; 2 h after exposure to the HESW, the high-energy phosphate resonances had decreased drastically. This decline in energy rich molecules was accompanied by a concomitant increase in the inorganic phosphate resonance and a decrease in pH of the tumor. During the following period, a dose-time dependent recovery of the original high-energy phosphate resonance intensities was observed. These changes are qualitatively similar to those produced by ischemic inhibition of energy metabolism and are correlated with early histological features like vascular disruption, stasis within capillaries, and focal thrombosis. These results demonstrate that experimental HESW treatment of the NU-1 kidney tumor is effective in provoking a temporary reduction of both high-energy phosphate metabolism and tissue pH of the tumor. The data presented here strongly suggest that these effects are predominantly indirect by affecting tumor vascularity. Overall, this study shows that MRS is a powerful technique for longitudinal investigations of HESW-induced effects and can provide information about its mode of action.

Serum creatine kinase BB as predictor of periventricular haemorrhage in preterm infants.

Serum creatine kinase BB (CK-BB) determinations were performed daily in 49 newborn infants of less than 34 weeks gestation to evaluate its usefulness in predicting the occurrence of periventricular-intraventricular haemorrhage (PIVH). Using ultrasound PIVH was detected in 20 infants (41%); five grade I, seven grade II, two grade III, six grade IV (grading according to Papile et al.). Infants who developed severe PIVH (grade IV) during the study period had significantly higher serum CK-BB activities immediately after birth when compared with infants who developed less severe haemorrhages (grades I, II and II) or no PIVH. We postulate that these high serum enzyme activities are caused by perinatal brain cell damage which is an important antecedent of severe PIVH. Therefore, serum CK-BB activities at birth can be used as predictor of severe PIVH.

The viability of the preterm infant.

Viability is the capability of the liveborn infant to survive without major handicaps. Although opinions differ in the Netherlands as to the justification of starting treatment in infants of less than 26 weeks gestation, our preliminary results indicate that mortality and major-handicap rate do not differ in infants of less than 26 weeks compared to infants of 26 and 27 weeks. However, we should encourage preventive perinatal medicine in order to reduce the alarming high rate of major handicaps in all extremely preterm infants.

Decreased cerebrovascular resistance in small for gestational age infants.

Using a transcutaneous Doppler technique we found a significantly lower cerebrovascular resistance and higher cerebral blood flow velocity indicating vasodilatation and increase of cerebral blood flow in small for gestational age infants compared with appropriate for gestational age infants during the first days of life. We speculate that these findings are due to a continuation of the fetal situation in which chronic hypoxia, mostly caused by pregnancy-induced hypertension, possibly causes a prostacyclin-induced vasodilatation.

Maternal hypertension and very preterm infants' mortality and handicaps.

In a nationwide survey on liveborn very preterm and/or very low birthweight infants in The Netherlands, mortality and handicaps at the corrected age of 2 years were studied in infants born to mothers with or without hypertensive disorders during pregnancy. The neonatal and in-hospital mortality was significantly lower in infants born to hypertensive mothers. In surviving infants, a similar handicap rate was found at the corrected age of 2 years for both groups.

Twenty-two years of intra-uterine intraperitoneal transfusions.

Over a period of 22 years, 154 fetuses were treated with 270 intra-uterine intraperitoneal transfusions. The patients were divided into three groups, according to the period they were treated. The overall percentage of surviving infants increased from 33% during the first period to 58% in the last period. In the group of infants that were not hydropic at the time of the first transfusion, the survival rate increased from 35 to 83%. In the group of children that were hydropic during the first transfusion, the survival rate during the first and last period was 24 and 42%, respectively. The percentage of fetuses that needed their first transfusion before the 26th week of pregnancy increased from 15 to 32% during the study period. Only 13% of these children survived. Lately, the intravascular approach has been introduced. Intravascular transfusions seem to be very effective, especially in early pregnancies and in hydropic fetuses. Application of the two techniques each in the most appropriate situation might offer optimal results for the near future.

The role of yearly chest radiography in the early detection of lung cancer following oral cancer.

In a study of 213 patients with oral cancer, we investigated the incidence and prognosis of lung malignancies in patients offered a yearly chest radiography in the follow-up. Three conclusions can be drawn. (1) Metastatic or primary lung cancer was diagnosed in 22 (10.3%) patients. The 2-year actuarial incidence rate of lung cancer following cancer of the oral cavity is 13%. No new lung cancers were detected after 2 years follow-up. This suggests that after this period, yearly chest radiography may be superfluous for the early detection of lung cancer. (2) The survival rate of patients with a lung malignancy following cancer of the oral cavity is poor (1-year = 25%). The survival rate of patients detected by the yearly chest radiography without symptoms is higher than for patients detected after symptoms (p = 0.006). It is not clear to what extent this different survival rate is biased by lead-time and selection of patients with a favourable prognosis. A randomized study would be required to assess whether patients with oral cancer do benefit from the yearly chest radiography compared with no regular chest radiography. (3) Of 22 patients with lung cancer, 13 (59%) were detected by chest radiography without symptoms. In the first year following oral cancer, 11 patients were diagnosed with lung cancer. Only 4 of these 11 patients (36%) were detected by chest radiography in an asymptomatic stage. The detection of patients with lung cancer in an asymptomatic stage may be increased by more frequent chest radiography examinations in the 1st year following oral cancer.

Hearing loss in very preterm and very low birthweight infants at the age of 5 years in a nationwide cohort.

In a geographically defined population of very preterm and very low birthweight infants (gestational age < 32 weeks and/or birthweight < 1500 g) hearing was evaluated in 890 children by pure-tone audiometry at the age of 5 years. Hearing loss was conductive/unspecified in 123 (13.8%) and sensorineural in 13 (1.5%) children. The prevalence of sensorineural hearing loss was 15 times as high as in 5-7 year old children in the Dutch population at large. The sensorineural hearing loss prevalence in very low birthweight and extremely low birthweight infants was similar. On account of communication disorders 10 (1.1%) children were classified as disabled and 6 (0.7%) as handicapped, following the definitions of the International Classification of Impairments, Disabilities, and Handicaps of the World Health Organisation. Children with conductive hearing loss had a higher risk of impairments, disabilities and handicaps of language and speech development, than children with normal hearing, the difference being statistically significant. The same holds for children with sensorineural hearing loss; moreover they had a significantly higher risk of impairments, disabilities and handicaps of mental development. Overall comparison of children with and without sensorineural hearing loss proved that the children with sensorineural hearing loss had a significantly less favourable outcome, based on 15 perinatal factors simultaneously. The age at which sensorineural hearing loss in very preterm and/or very low birthweight infants is detected has to be improved.

[Mortality risk after intrauterine and after neonatal transport]. / Sterftekans na intra-uterien en neonataal transport.

In a Dutch national collaborative study of 1338 newborn infants born in 1983 with a gestational age of less than 32 weeks and (or) a birth weight of less than 1500 g, a comparison was made of maternal transport to university perinatal centres and delivery in local general hospitals on the one hand, and neonatal transport to those centres and treatment in regional general hospitals on the other. The mortality risk was investigated by means of logistic regression analysis. The results show that maternal transport was accompanied by a statistically significantly lower mortality risk. The mortality risk after neonatal transport, compared with that after treatment in regional hospitals, was also lower although not significantly. Mortality risk after neonatal transport was significantly associated with increasing transportation distance. The results of the study confirm that referral by maternal transport offers the best prospects for high risk preterm babies.

[Birth weight percentiles of premature infants needs to be updated]. / Percentielgrenzen voor geboortegewicht van vroeggeborenen moeten worden herzien.

OBJECTIVE: To analyse whether the conventional so-called Kloosterman charts for birthweight of preterm infants based on data from 1931-1965 are still valid. DESIGN: Descriptive investigation. LOCATION: The Netherlands. METHOD: Data were obtained from the 'project of the premature and small for gestational age' (POPS) survey in 1983. The population consisted of 855 Caucasian infants born after a pregnancy of 24-31 weeks. RESULTS: In nearly all gestational age categories the percentages of small-for-gestational age infants were higher than the 10% they should have been by definition; the percentages of large-for-gestational age infants were much lower than 10%. After exclusion of elective births the percentages remained different. CONCLUSION: These shifts in the birthweight distribution are probably the result of changes in obstetrics. The birthweight percentiles for preterm births will have to be updated.

[Congenital disorders in the first year of life]. / Congenitale afwijkingen in het eerste levensjaar in Nederland.

OBJECTIVE: Assessment of the prevalence of congenital malformations in a population-based birth cohort of 2151 children. METHOD: Information about congenital malformations was obtained of 2092 infants by the Child Health Clinic nurses and by the CHC physician during six consultations in the first year of life. RESULTS: In 29% of the infants a congenital malformation was diagnosed. In 37 children (1.8%) 40 major malformations were found. More than three quarters of the malformations were diagnosed in the first three months of life. Using the EUROCAT criteria, a difference existed between the incidence of congenital malformations in liveborn infants in SMOCK (4.0%) and in EUROCAT (2.3%). This difference is mainly caused by the difference in the number of reports on congenital hip dislocation. The prevalence of major defects was similar in both SMOCK (central nervous system: 14/10,000; circulatory system: 67/10,000; ventricular septal defect 29/10,000; schisis: 14/10,000; Down syndrome: 14/10,000) and EUROCAT: CONCLUSION: By systematic and structured reporting it is possible to obtain more complete information on the prevalence of congenital malformations than by voluntary notification. One quarter of the congenital malformations is not detected before the age of 3 months.

[The significance of convulsion-like signs in the first 2 years of life]. / De betekenis van convulsieachtige verschijnselen in de eerste twee levensjaren.

OBJECTIVE: Assessment of the prevalence of convulsion-like symptoms in 1854 children of Dutch-speaking mothers of a population-based birth cohort. METHOD: At each child health clinic (CHC) visit mothers were asked whether they had noted any of the following signs: loss of consciousness, involuntary movements, eye rotation movements and apnoea, and if so, whether these appeared to be related to feeding. Registration was done by the CHC physician during eight consultations. RESULTS: Convulsion-like symptoms occurred in a quarter of the children: in 8% exclusively in relation to feeding, almost without exception in the first three months of life, in 19% also without relation to feeding, continuing until the second birthday. The latter children were more frequently admitted into hospital, even for non-neurological problems, than the former or than children without any such signs. They also have more disabilities at the age of two years. No connection with epilepsy in the family or with congenital anomalies could be demonstrated. CONCLUSION: Convulsion-like symptoms were observed in a quarter of children up to the age of two years. Special attention should be paid by the CHC team to children with signs not connected with feeding.