Outcome for children treated with fetal intravascular transfusions because of severe blood group antagonism.

OBJECTIVE: To describe the outcome for 92 fetuses treated between May 1987 and January of 1993 with intrauterine (intravascular) transfusions for severe hemolytic disease in comparison with a high-risk and a healthy control group. STUDY DESIGN: Information on the perinatal period was obtained from the patient records. The children regularly attended the outpatient clinic, and a general pediatric examination was performed on each visit. The psychometer development of the child until age 4 1/2 years was assessed according to Gesell. At the age of 5 years, the adaptation part of the Denver Developmental Screening Test and a Dutch-language test were used. A neurologic examination was performed according to Touwen. RESULTS: In our study, 77 (83.7%) of 92 fetuses were born alive after intravascular transfusions. The overall survival rate was 79.3%. The follow-up group included 69 infants, with an age range of 6 months to 6 years. Correlation between antenatal and perinatal features showed a significant negative relationship between the number of intrauterine transfusions and the duration of phototherapy (p = 0.002). The probability that neurologic abnormalities would occur was significantly greater when perinatal asphyxia had been present (p < 0.05) and with a lower cord hemoglobin level at birth (p = 0.03). The total number of children with disabilities was 10.1% (7/69). CONCLUSIONS: The neurodevelopmental outcome for the group of survivors compared favorably with a group of high-risk, very low birth weight infants (10.1% to 18%), and less favorably with a healthy control group (10.1% to 6%).

Cerebral blood volume changes during exchange transfusions in infants born at or near term.

We investigated the effects on cerebral hemodynamics of blood pressure changes during exchange transfusions in infants born at or near term, using near infrared spectroscopy in eight stable infants (mean gestational age, 36.2 +/- 1.3 weeks) who underwent a total of 21 exchange transfusions for erythroblastosis fetalis (rhesus hemolytic disease). Changes in mean arterial blood pressure derived from an indwelling umbilical arterial catheter, transcutaneous arterial oxygen and carbon dioxide tension, as well as changes in cerebral oxygenated hemoglobin (HbO2), deoxygenated hemoglobin (HbR), and total hemoglobin (Hbtot = HbO2 + HbR), were recorded continuously from 15 minutes before until the completion of the exchange transfusion. Relative change(s) in cerebral blood volume (dCBV) were calculated as follows: dCBV = change in Hbtot x 0.89/Venous hemoglobin. Changes in mean arterial blood pressure and dCBV were observed during all exchange transfusions; a decrease was found during the withdrawal period and an increase during the infusion period. The mean response of dCBV to a change in mean arterial blood pressure was 0.011 ml.100 gm-1.mm Hg. Multivariate analysis showed that dCBV were primarily associated with changes in mean arterial blood pressure, followed by changes in arterial oxygen tension and in exchange cycle duration. We conclude that in stable term and near-term infants, hemorrhagically induced blood pressure changes provoke dCBV.

School performance at nine years of age in very premature and very low birth weight infants: perinatal risk factors and predictors at five years of age. Collaborative Project on Preterm and Small for Gestational Age (POPS) Infants in The Netherlands.

To assess the impact of both perinatal disorders and developmental problems identified at preschool age on school performance, we followed a virtually complete birth cohort of very premature (< 32 completed weeks of gestation) and very low birth weight infants until they were 9 years of age. In 84% of the survivors (n = 813), data on school performance were available for analysis. At the age of 9 years, 19% of the children were in special education. Of the children in mainstream education, 32% were in a grade below the appropriate level for age and 38% had special assistance. After correction for other perinatal items, children of low socioeconomic status and boys had significantly higher adjusted odds ratios for special education. Logistic regression with a perinatal and a 5-year time category showed that the most predictive factors for special education were developmental delay, neuromotor and speech/language function, inattention and hyperactivity score, total problem score, and reported school results at the age of 5 years. When children with disabilities were left out of the analysis, the importance of neuromotor function and total problem score disappeared. Increased risks of any school failure in nondisabled children included mild or severe developmental delay and marginal or poor school performance at the age of 5 years. Long-term follow-up with specific attention to these predictors at 5 years of age, although time-consuming, is necessary.

Is it correct to correct? Developmental milestones in 555 "normal" preterm infants compared with term infants.

To determine whether correction for preterm birth should be applied during developmental assessment, we conducted a prospective national survey of very premature infants (born at less than 32 weeks of gestation); neurodevelopment in the first 2 years was studied with the Dutch child health care developmental assessment. In 555 preterm children who had no evidence of handicap at 2 years of age, the age at which developmental milestones were reached was established. The results were compared with the results of the same assessment in Dutch children born at term. During the first year, the development of the very premature children equaled the development of normal children when full correction was applied. At 2 years of age, development was equal to or better than normal children's development without correction. We conclude that full correction for prematurity should be applied in the first year to avoid overreferral for developmental stimulation, whereas at 2 years of age correction is not necessary.