Review of the antenatal and postnatal use of steroids.

Antenatal and postnatal corticosteroids play an extremely important role in the management of premature infants. The antenatal administration of steroids has been universally implemented. They have not only been shown to reduce the incidence and severity of respiratory distress syndrome (RDS), but also have an impact on the incidence of intraventricular hemorrhage (IVH), patent ductus arteriosus (PDA), necrotizing enterocolitis (NEC), and possibly retinopathy of prematurity (ROP) by reducing the need for supplemental oxygen due to improved lung function. The postnatal use of dexamethasone in ventilated infants has been adopted with caution, as there have been several reports of long-term neurodevelopmental complications with this therapy. Hence, changes in dosage and indications and the search for alternative therapies has emerged. Hydrocortisone appears to be a good alternative, with reassuring long-term evaluations thus far.

The ethics and practice of neonatal resuscitation at the limits of viability: an international perspective.

UNLABELLED: Premature infants at the limits of viability raise difficult ethical, legal, social and economic questions. Neonatologists attending an international Collegium were surveyed about delivery room behaviour, and the approach taken by selected countries practicing 'modern' medicine was explored. CONCLUSION: There were strong preferences for comfort care at 22 weeks and full resuscitation at 24 weeks. Resuscitation was a grey area at 23 weeks. Cultural, social and legal factors also had a considerable impact on decision-making.

Are antenatal steroids beneficial to severely growth restricted fetuses?

Antenatal steroids (AS) have been shown to enhance fetal maturation in preterms and to improve outcome. The aim of this study was to evaluate the efficacy of AS in premature severely intrauterine growth restricted infants. The electronic data of 149 inborn, single infants born 24 to 31 6/7 weeks of GA and with a BW ≤ 3rd percentile were reviewed. Infants with congenital anomalies and syndromes were excluded. We compared the outcome of those who received 2 doses of AS (group A, 87 infants) with those who did not receive AS (group B, 62 infants). Sixty-eight infants in group A and 53 in group B were discharged home alive. AS did not improve the neonatal outcome, with the exception of a better cord pH and 5-min Apgar and we did not observe a significant difference in the Griffith's test at 2 years of corrected age, although there was a trend to a higher incidence of severe global delay in the steroid group. In view of the potential cerebral and CVS risks associated with high circulating steroids, the indications for AS in such a population need to be re-evaluated.

Easing maternal anxiety: an update.

Maternal mental health is an important public health issue because of its effects not only on the mother's well-being and functional status, but also her relationship with her partner and the development of her children. There is accumulating evidence of the adverse sequelae of maternal anxiety on fetal development, obstetrical complications, pregnancy outcomes such as low birth weight, and subsequent child development. Evaluation of maternal anxiety and intervention to reduce these symptoms, may ensure optimal developmental outcomes, particularly in high-risk infants such as those born at very low birth weights. This article will outline recent advances in our understanding of the etiology, assessment and impact of maternal anxiety, and describe intervention strategies to promote maternal well-being.

The cues and care randomized controlled trial of a neonatal intensive care unit intervention: effects on maternal psychological distress and mother-infant interaction.

OBJECTIVE: This study tested the efficacy of a brief intervention (Cues program) with mothers of very low birth weight (VLBW <1500 g) infants. The primary hypothesis was that mothers in the Cues program would report lower levels of anxiety compared with mothers in the control group. Secondary hypotheses examined whether Cues mothers would report less stress, depression, and role restriction, and exhibit more sensitive interactive behavior, than control group mothers. METHODS: A total of 121 mothers of VLBW infants were randomly assigned to either the experimental (Cues) intervention or an attention control (Care) condition. The Cues program combined training to reduce anxiety and enhance sensitivity. The control group received general information about infant care. Both programs were initiated during the neonatal intensive care unit stay. Maternal anxiety, stress, depression, and demographic variables were evaluated at baseline, prior to randomization. Postintervention outcomes were assessed during a home visit when the infant was ∼6 to 8 weeks of corrected age. RESULTS: Although mothers in the Cues group demonstrated greater knowledge of the content of the experimental intervention than mothers in the Care group, the groups did not differ in levels of anxiety, depression, and symptoms of posttraumatic stress. They were similar in their reports of parental role restrictions and stress related to the infant's appearance and behavior. Cues and Care group mothers were equally sensitive in interaction with their infants. CONCLUSION: Nonspecific attention was as effective as an early skill-based intervention in reducing maternal anxiety and enhancing sensitive behavior in mothers of VLBW infants.

Early maternal anxiety predicts cognitive and behavioural outcomes of VLBW children at 24 months corrected age.

AIM: The present study examined the effects of maternal anxiety during infant hospitalization in the Neonatal Intensive Care Unit (NICU) on the child's cognitive and behavioural development at 24 months corrected age. Parental anxiety following the birth of a very low birthweight (VLBW, <1500 g) infant may impede their capacity to be sensitive to the infant's cues and adversely affect infant developmental outcomes. METHODS: A sample of 88 mothers and their VLBW infants were recruited in the NICU; 57 were followed at 24 months corrected age. During the infant's hospitalization, mothers completed a self-report measure of trait anxiety. When the infants were 24 months corrected age, mother-child interaction was videotaped during free play at home. These videotaped observations were coded using Emotional Availability Scales. Child cognitive and behavioural outcomes were evaluated using the Bayley Scales of Infant Development (II) and the Child Behavior Checklist for Ages 1.5-5. RESULTS: Maternal anxiety in the NICU was found to be a significant and independent predictor of child cognitive development and internalizing behaviour problems, controlling for maternal education and neonatal morbidity. CONCLUSION: These results suggest that early intervention programmes targeting anxious mothers of VLBW infants are indicated, to promote optimal developmental outcomes.

Posttraumatic stress among mothers of very low birthweight infants at 6 months after discharge from the neonatal intensive care unit.

This correlational study examined how mother's posttraumatic stress disorder (PTSD) symptoms are related to characteristics of the mother and her infant, as well as to mother-infant interaction and infant development, in 21 mothers of very low birthweight infants. Twenty-three percent of mothers scored in the clinical range on a measure of PTSD. How ill the infant was during the NICU hospitalization was related to mothers' PTSD symptoms. Mothers with greater PTSD symptoms were less sensitive and effective at structuring interaction with their infant.

Persistent maternal anxiety affects the interaction between mothers and their very low birthweight children at 24 months.

BACKGROUND: Parental distress following the birth of a premature infant diminishes the parent's ability to be sensitive to the infant's cues, and this may affect infant developmental outcomes. AIMS: The present study examined the effects of maternal anxiety during infant hospitalization in the Neonatal Intensive Care Unit (NICU) on the interactive behavior of mothers with their very low birthweight (VLBW) children in toddlerhood. SUBJECTS: A sample of 56 mothers and their VLBW infants were recruited in the NICU. STUDY DESIGN: During the infant's NICU stay, mothers completed a self-report measure of trait anxiety. These mothers and their infants were followed when the infants were 24 months corrected age, when mothers and their children were videotaped during free play at home. These videotapes were then coded using the Emotional Availability Scales. RESULTS: Maternal anxiety was not found to be related to severity of neonatal illness. Maternal anxiety in the NICU was associated with less sensitivity and less structure in interaction with their toddlers at 24 months corrected age, even controlling for maternal education and child birthweight. Children of mothers with higher anxiety scores in the NICU were less likely to involve their mothers in their play at 24 months corrected age. CONCLUSIONS: Maternal anxiety in the NICU predicted adverse interactive behaviors when the children were 24 months corrected age. Early identification of anxious mothers in the NICU is needed in order to initiate preventive intervention to support the mother-infant relationship.

Assessing the feasibility and acceptability of an intervention to reduce anxiety and enhance sensitivity among mothers of very low birth-weight infants.

PURPOSE: A pilot study was conducted to assess the feasibility and acceptability of an intervention program for mothers of very low birth-weight infants in the neonatal intensive care unit (NICU). SUBJECTS: Thirty-three mothers of infants born weighing less than 1500 g. DESIGN: A single-group, pretest-posttest design was used. METHODS: Preintervention mothers completed self-report questionnaires and their interaction with their infant was observed. Mothers then received the intervention program. Mothers were assessed twice postintervention, first when the infant was 1/2 months old and again at 6 months. At the postintervention assessments, mothers completed the same questionnaires and interaction was observed. MAIN OUTCOME MEASURES: Mothers completed the State-Trait Anxiety Inventory, the revised Parental Stress Scale: Neonatal Intensive Care Unit, the NICU Parental Beliefs Scale, and the Perinatal PTSD Questionnaire. Interactions between mothers and infants were rated by trained research staff using the Index of Parental Behaviour in the NICU. Postintervention mothers also responded to a questionnaire that assessed their perceptions of the intervention program. RESULTS: It was feasible to enroll mothers because 62% of eligible mothers agreed to participate. However, 39% of mothers who enrolled withdrew. Most of the mothers who withdrew did so before even beginning the intervention, and many of these women were mothers of multiples. It was also feasible to provide the intervention because more than 80% of mothers who began the intervention received all 6 teaching sessions. Mothers found both the content and the format of the program to be acceptable. There were nonetheless several challenges in conducting an intervention study with mothers early in the NICU hospitalization. CONCLUSIONS: The results of this pilot study are encouraging. It was found to be both feasible and acceptable to provide the intervention program to mothers during the NICU hospitalization. The effectiveness of this program needs to be assessed in a randomized controlled trial.

The Cues and Care Trial: a randomized controlled trial of an intervention to reduce maternal anxiety and improve developmental outcomes in very low birthweight infants.

BACKGROUND: Very low birthweight infants are at risk for deficits in cognitive and language development, as well as attention and behaviour problems. Maternal sensitive behaviour (i.e. awareness of infant cues and appropriate responsiveness to those cues) in interaction with her very low birthweight infant is associated with better outcomes in these domains; however, maternal anxiety interferes with the mother's ability to interact sensitively with her very low birthweight infant. There is a need for brief, cost-effective and timely interventions that address both maternal psychological distress and interactive behaviour. The Cues and Care trial is a randomized controlled trial of an intervention designed to reduce maternal anxiety and promote sensitive interaction in mothers of very low birthweight infants. METHODS AND DESIGN: Mothers of singleton infants born at weights below 1500 g are recruited in the neonatal intensive care units of 2 tertiary care hospitals, and are randomly assigned to the experimental (Cues) intervention or to an attention control (Care) condition. The Cues intervention teaches mothers to attend to their own physiological, cognitive, and emotional cues that signal anxiety and worry, and to use cognitive-behavioural strategies to reduce distress. Mothers are also taught to understand infant cues and to respond sensitively to those cues. Mothers in the Care group receive general information about infant care. Both groups have 6 contacts with a trained intervener; 5 of the 6 sessions take place during the infant's hospitalization, and the sixth contact occurs after discharge, in the participant mother's home. The primary outcome is maternal symptoms of anxiety, assessed via self-report questionnaire immediately post-intervention. Secondary outcomes include maternal sensitive behaviour, maternal symptoms of posttraumatic stress, and infant development at 6 months corrected age. DISCUSSION: The Cues and Care trial will provide important information on the efficacy of a brief, skills-based intervention to reduce anxiety and increase sensitivity in mothers of very low birthweight infants. A brief intervention of this nature may be more readily implemented as part of standard neonatal intensive care than broad-based, multi-component interventions. By intervening early, we aim to optimize developmental outcomes in these high risk infants. TRIAL REGISTRATION: Current Controlled Trials ISRCTN00918472. The Cues and Care Trial: A randomized controlled trial of an intervention to reduce maternal anxiety and improve developmental outcomes in very low birthweight infants.

Anxiety affects the relationship between parents and their very low birth weight infants.

The goal of this study was to examine the medical and sociodemographic factors associated with parental anxiety following the birth of a very low birth weight infant (VLBW, below 1500 g), and to determine the impact of anxiety on the behavior of parents with their VLBW infants in the Neonatal Intensive Care Unit (NICU). The parents of 88 VLBW infants were recruited through the NICU of a tertiary-care hospital, approximately 2 weeks following delivery. Parents completed self-report questionnaires measuring anxiety, marital quality, and social support. Prior to discharge, each parent was observed twice during a feeding interaction with the infant. Maternal anxiety was greater when their infants were smaller in terms of birth weight and younger in gestational age. Maternal education, marital status, and country of origin, as well as social support and marital quality, were also associated with anxiety. Paternal anxiety was not related to socioeconomic status or infant medical risk, but was associated with country of origin, social support, and marital quality. For both mothers and fathers, anxiety was a better predictor of parental behavior than was infant medical risk. These findings suggest the need to intervene with anxious parents in order to promote satisfactory parent-infant relationships.

A typical feeding enhances memory for spoken words in healthy 2- to 3-day-old newborns.

OBJECTIVE: The objective of this study was to determine whether healthy 2- to 3-day-old newborns have better memory of a spoken word after a typical feeding (breast milk or formula) than before a feeding and, if so, whether memory is related to blood glucose. METHODS: A naturalistic study was conducted in which delayed recognition memory of a spoken word was examined in 60 healthy 2- to 3-day-old newborns either 120 minutes after their previous feeding (preprandial) or 30 minutes after their last feeding (postprandial). In this procedure, infants initially turn their head toward a novel word (orientation) and with repeated presentations cease turning toward it (habituation). Mean number of trials to reach orientation and habituation criteria provides measures of attention and rate of learning, respectively. After a 100-second delay, the word is presented again. Infants either turn toward it, indicating that they have forgotten it, or remain habituated, indicating that they remembered the word. Percentage of trials with head turns toward the word after the delay is the principal dependent measure. RESULTS: The postprandial group was split at the median for blood glucose to define high- and low-glucose groups. All 3 groups showed similar rates of orientation and habituation. On reexposure to the word during postdelay trials, the preprandial group displayed less retention than the postprandial high and low groups. No correlation was found between memory and blood glucose levels. The postprandial high blood glucose level differed statistically from the preprandial level, whereas the postprandial low level did not. CONCLUSIONS: Memory for spoken words in newborns is better after a typical milk feeding than before a feeding. This feeding effect is specific to memory and does not include attention or rate of learning. Also, it is not necessarily associated with increased blood glucose. It remains to be seen whether feeding enhances memory for other types of stimuli and what implications this may have for development.

Maternal anxiety: an emerging prognostic factor in neonatology.

UNLABELLED: Symptoms of anxiety in pregnant and postpartum women are of considerable concern due to their association with adverse obstetrical outcomes, postpartum depression, and emotional and behavioral problems in the children. Certain mothers are at particularly high risk for anxiety in the immediate postpartum period: those who have experienced preterm birth or other perinatal complications, as well as those lacking a satisfactory marital relationship or other forms of social support. CONCLUSION: Programs to detect and intervene with anxious mothers in the early postpartum period are warranted.

Outcome at 5 years of age of SGA and AGA infants born less than 28 weeks of gestation.

The objective of this study was to compare the outcomes at 5 years of age of SGA and AGA children born < 28 weeks of gestation. The method used was a longitudinal follow-up of a cohort of 37 dyads of SGA and AGA infants matched by gestational age (GA), gender, and date of delivery. Mean GA was 26+/-1.2 weeks, and BW was 638+/-77 g for SGA and 833+/-134 g for AGA (P < 0.0001). The SGA infants remained lighter at 3, 24, and 60 months. Their head circumference was statistically smaller at 3 and 60 months, and their length remained lower but no longer statistically significant. There was no difference after the second year of life between SGA and AGA children in the need for rehospitalization (16% versus 11%) and the incidence of medical problems such as Otitis (38% versus 41%) and asthma (24% versus 30%). SGA exhibited more neurodevelopmental deficits (41% versus 30%) and severe handicaps, including CP, blindness, deafness, and mental retardation (22% versus 14%). Those deficits were seen predominantly in association with microcephaly, which was more prevalent in the SGA group. We conclude that the combination of severe prematurity and intrauterine growth retardation constitutes a serious developmental handicap and predisposes to physical and developmental delays. The presence of microcephaly further aggravates the prognosis.

Section 2 : Seismology

On August 17 and November 12, 1999 there were two earthqueakes in Turkey originated on the North Anatolian Fault Zone (NAFZ). The study of the NAFZ system provides an excellent opportunity to test and validate new approaches to updateable forecasts of hearthquakes hazard

Two-and three-dimensional effects on ground motion

Geologic conditions and topography at, or near, a site are known to exert a very significant influence on the nature of ground shaking, and their importance on seismic hazard has long been recognized. In particular, sedimentary deposits in the form of sediment-filled valleys or basins very often have a pronounced effect on the intensity of strong ground motion. The finite lateral extent of the sedimentary deposit introduces complex effects through the generation pf surface waves (referred to as locally generated (or valley induced) surface waves) at the edges and resonance in the lateral direction, and tends to increase both the amplitude and the duration of the ground motion. Therefore, for the correct interpretation and/or reliable prediction of strong ground motion, as much insight as possible must be gained about the response of these geologic structures. This can be accomplished by theoretical modelling and by comparing/validating the predictions of theoretical models with recorded data.(AU)