Neurogenic fever after traumatic brain injury: an epidemiological study.

OBJECTIVES: To determine the incidence of neurogenic fever (NF) in a population of patients in the acute phase following severe traumatic brain injury (TBI); to identify factors associated with the development of NF following severe TBI in adults. METHODS: Charts of patients admitted from 1996 to 1999 with severe TBI at a large, urban mid-Atlantic teaching hospital were retrospectively evaluated based on diagnostic criteria for each episode of hyperthermia to determine the diagnosis of NF. Data were collected regarding mechanism and area of injury, severity of injury, and demographic factors to determine potential predictors of NF. RESULTS: Diffuse axonal injury (DAI) (OR 9.06, 95% CI 0.99 to 82.7) and frontal lobe injury of any type (OR 6.68, 95% CI 1.1 to 39.3) are independently predictive of an increased risk of development of NF following severe TBI. The presence of a skull fracture and lower initial Glasgow Coma Score (GCS) were individual predictors of development of NF, but did not contribute to the final model. CONCLUSIONS: These findings examine known and novel risk factors for this phenomenon in comparison to previously published literature on NF. A set of predictor variables was identified to help clinicians target patients at high risk for development of NF following severe TBI. It is hoped that earlier diagnosis and appropriate intervention for fever in the TBI patient will lead to improved outcomes.

Practice parameter: neuroimaging of the neonate: report of the Quality Standards Subcommittee of the American Academy of Neurology and the Practice Committee of the Child Neurology Society.

OBJECTIVE: The authors reviewed available evidence on neonatal neuroimaging strategies for evaluating both very low birth weight preterm infants and encephalopathic term neonates. IMAGING FOR THE PRETERM NEONATE: Routine screening cranial ultrasonography (US) should be performed on all infants of <30 weeks' gestation once between 7 and 14 days of age and should be optimally repeated between 36 and 40 weeks' postmenstrual age. This strategy detects lesions such as intraventricular hemorrhage, which influences clinical care, and those such as periventricular leukomalacia and low-pressure ventriculomegaly, which provide information about long-term neurodevelopmental outcome. There is insufficient evidence for routine MRI of all very low birth weight preterm infants with abnormal results of cranial US. IMAGING FOR THE TERM INFANT: Noncontrast CT should be performed to detect hemorrhagic lesions in the encephalopathic term infant with a history of birth trauma, low hematocrit, or coagulopathy. If CT findings are inconclusive, MRI should be performed between days 2 and 8 to assess the location and extent of injury. The pattern of injury identified with conventional MRI may provide diagnostic and prognostic information for term infants with evidence of encephalopathy. In particular, basal ganglia and thalamic lesions detected by conventional MRI are associated with poor neurodevelopmental outcome. Diffusion-weighted imaging may allow earlier detection of these cerebral injuries. RECOMMENDATIONS: US plays an established role in the management of preterm neonates of <30 weeks' gestation. US also provides valuable prognostic information when the infant reaches 40 weeks' postmenstrual age. For encephalopathic term infants, early CT should be used to exclude hemorrhage; MRI should be performed later in the first postnatal week to establish the pattern of injury and predict neurologic outcome.

Behavioural problems in children who weigh 1000 g or less at birth in four countries.

BACKGROUND: The increased survival chances of extremely low-birthweight (ELBW) infants (weighing <1000 g at birth) has led to concern about their behavioural outcome in childhood. In reports from several countries with different assessments at various ages, investigators have noted a higher frequency of behavioural problems in such infants, but cross-cultural comparisons are lacking. Our aim was to compare behavioural problems in ELBW children of similar ages from four countries. METHODS: We prospectively studied 408 ELBW children aged 8-10 years, whose parents completed the child behaviour checklist. The children came from the Netherlands, Germany, Canada, and USA. The checklist provides a total problem score consisting of eight narrow-band scales. Of these, two (aggressive and delinquent behaviour) give a broad-band externalising score, three (anxious, somatic, and withdrawn behaviour) give a broad-band internalising score, and three (social, thought, and attention problems) indicate difficulties fitting neither broad-band dimension. For each cohort we analysed scores in ELBW children and those in normal- birthweight controls (two cohorts) or national normative controls (two cohorts). Across countries, we assessed deviations of the ELBW children from normative or control groups. FINDINGS: ELBW children had higher total problem scores than normative or control children, but this increase was only significant in European countries. Narrow-band scores were raised only for the social, thought, and attention difficulty scales, which were 0.5-1.2 SD higher in ELBW children than in others. Except for the increase in internalising scores recorded for one cohort, ELBW children did not differ from normative or control children on internalising or externalising scales. INTERPRETATION: Despite cultural differences, types of behavioural problems seen in ELBW children were very similar in the four countries. This finding suggests that biological mechanisms contribute to behavioural problems of ELBW children.

Relation of cranial ultrasound abnormalities in low-birthweight infants to motor or cognitive performance at ages 2, 6, and 9 years.

This study sought to determine whether neonatal cranial ultrasound abnormalities are related to motor and cognitive outcomes in low-birthweight (LBW, <2000 g) children without major motor or cognitive disability. The relation of neonatal cranial ultrasound abnormalities to motor performance and general cognitive ability at ages 2, 6, and 9 years was examined in a prospectively followed regional cohort of LBW children, excluding those with major disability, and controlling for other risk factors. Compared with children without ultrasound abnormalities, children with abnormalities indicative of ischemic white-matter injury had poorer motor performance at all three ages and, at age 2, lower general cognitive ability. The latter finding was not seen when motor performance was also controlled for. It was concluded that in LBW children without major motor or cognitive disability, ischemic white-matter injury indicated by neonatal cranial ultrasound abnormalities adversely affected motor performance at ages 2, 6, and 9 years, but not general cognitive ability.

Plasma thyroid hormones in premature infants: effect of gestational age and antenatal thyrotropin-releasing hormone treatment. TRH Collaborative Trial Participants.

Thyroid hormones are important for both perinatal adaptation and long-term psychomotor development; however, there is limited information on the effects of extreme prematurity and antenatal TSH-releasing hormone (TRH) treatment on pituitary-thyroid function. In this study we assayed plasma triiodothyronine (T3) and TSH in infants who were part of a collaborative trial of antenatal maternal TRH therapy. Within the control population (n = 166), infants of 24-28-wk and 28-32-wk gestational age had comparable levels of T3 (0.94 and 1.06 nmol/L, respectively) and TSH (5.7 and 7.2 mU/L) at birth, but the increases at 2 h and subsequent T3 levels were less in the 24-28 wk versus 28-32-wk gestation infants. In the TRH-treated group (n = 131), T3 was lower in the first day for infants delivered 7-72 h after antenatal TRH compared with control infants. TSH at birth was approximately 3.5-fold greater for infants delivered at 0-6 h after the last TRH dose compared with the control group and was suppressed in infants delivering at 7-36 h. T3 and TSH levels were not different between control and TRH-treated groups at 3-28 d of age. In TRH stimulation tests on d 28, control and TRH-treated groups had similar peak levels of TSH and incidence of exaggerated response (TSH > or = 35 mU/L). We conclude that extremely premature infants have a reduced postnatal surge in TSH and T3 and maintain lower T3 concentrations, probably reflecting tertiary hypothyroidism. The stimulatory and suppressive effects of antenatal TRH treatment observed at birth are transient and do not affect pituitary-thyroid responsiveness at 28 d of age.

Short interpregnancy interval and the risk of disabling cerebral palsy in a low birth weight population.

OBJECTIVE: The objective of this study was to investigate the relation of short interpregnancy interval and cerebral palsy (CP) in a low birth weight population in whom neonatal brain injury was systematically ascertained in the newborn period. STUDY DESIGN: We used data from a prospective cohort study of 1105 infants born < or = 2000 gm, designed to study the cause and consequences of neonatal brain injury. Of the 777 children with data on brain injury and CP, 382 were born to multiparous women, and 375 had information available to calculate interpregnancy interval, defined as the number of days from the end of the last pregnancy to conception of the index pregnancy. RESULTS: In the presence of the strong explanatory power of neonatal brain injury, short interpregnancy interval maintains an independent risk for disabling CP. CONCLUSION: In this cohort of low birth weight infants, short interpregnancy interval appears to represent a significant risk for the development of disabling CP.

Routine and influenza vaccination rates in children with asthma.

BACKGROUND: Children with asthma may be at increased risk for low immunization rates given that they have recurrent illnesses that often result in acute care visits to their pediatrician, visits to the emergency room, admissions to the hospital, and visits to subspecialists, where immunizations are not routinely administered. OBJECTIVES: To assess immunization rates for routine and influenza vaccines in children with asthma and assess factors that may contribute to delay. METHODS: We conducted a cross-sectional survey of 117 children aged 6 to 48 months with onset of asthma within the first 15 months of life. Subjects were recruited from an allergy and immunology clinic at an urban, tertiary care center. Those judged to have immunization delay did not have the required 4 DTP, 3 OPV, and 1 MMR vaccine by age 24 months (4:3:1 series). Receipt of influenza vaccine was determined for eligible children with moderate to severe asthma. RESULTS: Seventy-four (80%) children had up-to-date immunizations at age 24 months. Those with delay had fewer visits to a subspecialist than those who were up-to-date (1 versus 2 visits P = .010). Twenty-two (25%) of 87 eligible subjects received influenza vaccine. Recipients were more likely to have been hospitalized than nonrecipients (77% versus 49%, P = .022). CONCLUSIONS: Though the majority of young children with asthma were up-to-date for routine immunizations, only 25% of children with moderate to severe asthma received influenza vaccine. Greater efforts must be made by pediatricians and asthma subspecialists to ensure that children with moderate to severe asthma are immunized against influenza virus.

Antenatal thyrotropin-releasing hormone to prevent lung disease in preterm infants. North American Thyrotropin-Releasing Hormone Study Group.

BACKGROUND: Pulmonary disease is common in preterm infants, despite antenatal glucocorticoid therapy. The addition of antenatal thyrotropin-releasing hormone therapy has been reported to decrease pulmonary morbidity in these infants. METHODS: We enrolled 996 women at 13 North American centers who were in preterm labor at <30 weeks' gestation in a double-blind, placebo-controlled, randomized trial of antenatal thyrotropin-releasing hormone, given intravenously in four doses of 400 microg each at eight-hour intervals. The primary outcome was chronic lung disease or death of the infant on or before the 28th day after delivery, and secondary outcomes were respiratory distress syndrome and chronic lung disease or death at 36 weeks' postmenstrual age. Complete data were available for 981 women and their 1134 live-born infants. The 769 infants born at < or = 32 weeks' gestation were defined as the group at risk. RESULTS: There were no significant differences between the at-risk treatment and placebo groups in mean (+/-SD) birth weight (1109+/-354 vs. 1097+/-355 g), gestational age (27.9+/-2.1 vs. 27.9+/-2.1 weeks), sex, or race. The frequencies of respiratory distress syndrome (66 percent vs. 65 percent), death at 28 days (11 percent vs. 11 percent), chronic lung disease or death at 28 days (45 percent vs. 42 percent) and at 36 weeks (32 percent vs. 34 percent), and other neonatal complications as well as the severity of lung disease were not significantly different in the at-risk treatment and placebo groups. Similarly, there were no differences in outcome between the treatment and placebo groups for the infants born at >32 weeks' gestation. CONCLUSIONS: In preterm infants at risk for lung disease, antenatal administration of thyrotropin-releasing hormone and glucocorticoid is no more beneficial than glucocorticoid alone.

The apgar score and its components in the preterm infant.

OBJECTIVE: The Apgar score is well-characterized in full-term infants but not in premature infants. The objective of this study was to assess the Apgar score in preterm infants with respect to the relationships between the 1- and 5-minute scores, the correlation of the Apgar score with pH and with other variables, and the relationship among the individual Apgar components. METHODOLOGY: We recorded Apgar scores at 1 and 5 minutes in a population-based cohort of preterm infants (n = 1105) with birth weight <2000 g, from three intensive care nurseries in central New Jersey. Linear correlation analysis was used to examine the relationship between 1- and 5-minute Apgar scores and between the individual components of the Apgar score. Multiple regression analysis was used to explore the relationship between various perinatal characteristics and the Apgar score, and between pH and Apgar score. Stepwise logistic regression analysis was used to assess the determinants of mortality. RESULTS: The 1-minute Apgar score median (25%, 75%) was 6(4,8) and correlated with the 5-minute score of 8(7,9) at r = .78. Slight but significant differences were seen between male (n = 557) and female (n = 508) infants in the 1-minute (6[4,8] and 7[4,8]) Apgar scores. One- and 5-minute scores of white infants (7[4,8] and 8[7,9]; n = 713) were significantly higher than those of black infants (5[3,7] and 8[6,9]; n = 280). Birth weight and gestational age were both linearly related to both Apgar scores. Low Apgar score (<3 at 1 minute and <6 at 5 minutes) was significantly associated with birth weight, gestational age and mode of delivery. Low arterial blood pH (<7.01) at birth was significantly related to low Apgar score. One hundred fifty-nine infants died; these infants were significantly smaller (983 +/- 382 vs 1462 +/- 369 g), less mature (27 vs 31 weeks), had lower arterial blood pH (7.20 +/- 0.18 vs 7.31 +/- 0.11), had lower 1- (3[2,6] vs 7[4,8]) and 5-minute Apgar scores (6[4,8] vs 8[7,9]), and a greater incidence of low Apgar score (32% vs 6%) than did survivors. CONCLUSIONS: Among the components of the Apgar score, respiratory effort, muscle tone, and reflex activity correlated well with one another; heart rate correlated less well; and color the least. Our data confirms the limited use of the Apgar score in preterm infants and demonstrates the different responses of the Apgar score's components.

Psychiatric outcomes in low-birth-weight children at age 6 years: relation to neonatal cranial ultrasound abnormalities.

BACKGROUND: This study examined the relation of neonatal cranial ultrasound abnormalities to psychiatric disorder at age 6 years in a regional birth cohort of low-birth-weight children. METHODS: Neonatal cranial ultrasound abnormalities were classified as (1) isolated germinal matrix and/or intraventricular hemorrhage (suggestive of injury to glial precursors) or (2) parenchymal lesions and/or ventricular enlargement (suggestive of white matter injury) with or without germinal matrix-intraventricular hemorrhage. Psychiatric disorders by DSM-III-R at age 6 years were assessed by means of a structured parent interview. Children with severe mental retardation were excluded. Analyses were conducted first in the entire sample and then in children with normal intelligence. RESULTS: Twenty-two percent of the cohort had at least 1 psychiatric disorder, the most common being attention deficit hyperactivity disorder (15.6%). In the entire sample, parenchymal lesions and/or ventricular enlargement increased risk relative to no abnormality, independently of other biological and social predictors, for any disorder (odds ratio [OR], 4.4; 95% confidence interval [CI], 1.8-10.3; P < .001), attention deficit hyperactivity disorder (OR, 3.4; CI, 1.3-8.7; P = .02), and tic disorders (OR, 8.7; CI, 1.3-57.7; P = .02). In children of normal intelligence, parenchymal lesions/ventricular enlargement independently increased risk for any disorder (OR, 4.8; CI, 1.6-12.0; P < .01), attention deficit hyperactivity disorder (OR, 4.5; CI, 1.3-16.0; P = .02), and separation anxiety (OR, 5.3; CI, 1.1-24.8; P = .03). These effects were not ameliorated by female sex or social advantage. Isolated germinal matrix/intraventricular hemorrhage was not related to psychiatric disorder at age 6 years. CONCLUSION: Neonatal cranial ultrasound abnormalities suggestive of white matter injury significantly increased risk for some psychiatric disorders at age 6 years in low-birth-weight children.

Teen father participation in child rearing: family perspectives.

OBJECTIVES: To explore adolescent fatherhood from the perspectives of teen fathers, teen mothers, paternal grandmothers (PGMs), and maternal grandmothers (MGMs). To identify perceived barriers to and recommendations for the enhancement of teen father participation in child rearing. METHODS: A total of 61 teen parents participated in the design of a structured interview. A community-based sample of 173 teen fathers, 167 teen mothers, 76 PGMs, and 79 MGMs were interviewed by teenage assistants. Multiple logistic regression analysis using maximum likelihood estimation and the best subset algorithm identified barriers most predictive of paternal uninvolvement in child rearing. RESULTS: Fifty-four percent of teen fathers and 70% of partners of teen mothers' met the definition of involvement in child rearing. Disinterest in child rearing most consistently predicted uninvolvement. Fathers were less likely than mothers to report paternal disinterest as a barrier and more likely to attribute their lack of involvement to resistance from mothers and MGMs (p < 0.05). The best model predicting paternal involvement from the fathers' perspective included paternal disinterest [odds ration (OR) = 0.42, confidence interval (CI) = 0.19-0.92] and age (OR = 0.74, CI = 0.56-0.97). The best model from the mothers' perspective included paternal disinterest (OR = 0.16, CI = 0.07-0.36) and lack of time (OR = 0.31, CI = 0.15-0.91). Of those fathers who cited disinterest, there was an association with lack of money (p = 0.002) and lack of knowledge of child care (p = 0.069. While fathers and mothers disagreed on several interventions, they agreed (82% and 95%, respectively) that availability of jobs would promote paternal involvement. CONCLUSIONS: Most teen fathers in this study were involved and interested in child rearing. A young father's financial insecurity or confusion about child care was most likely to lead to a stated disinterest, and that disinterest predicted uninvolvement.

PIP: A community-based sample of 173 teen fathers, 167 teen mothers, 76 paternal grandmothers, and 79 maternal grandmothers was interviewed by teenage assistants to explore adolescent fatherhood from a range of differing perspectives. 54% of teen fathers and 70% of partners of teen mothers met the definition of involvement in child rearing. Disinterest in child rearing most consistently predicted uninvolvement. Fathers were less likely than mothers to report paternal disinterest as a barrier and more likely to attribute their lack of involvement to resistance from mothers and maternal grandmothers. The best model predicting paternal involvement from the fathers' perspective included paternal disinterest and age, while the best model from the mothers' perspective included paternal disinterest and lack of time. Of those fathers who cited disinterest, there was an association with lack of money and lack of knowledge of child care. While fathers and mothers disagreed upon several interventions, they agreed that an availability of jobs would promote paternal involvement.

Magnesium sulfate in labor and risk of neonatal brain lesions and cerebral palsy in low birth weight infants. The Neonatal Brain Hemorrhage Study Analysis Group.

OBJECTIVES: We tested the hypothesis that administration of magnesium sulfate in labor protects against the development of neonatal brain lesions and cerebral palsy (CP) in low birth weight infants. METHODS: Magnesium exposure was ascertained in a population-based cohort of 1105 infants weighing 2000 g or less through review of medical records of maternal magnesium sulfate administration and, where available, elevated maternal serum magnesium levels. Neonatal germinal matrix/intraventricular hemorrhage and parenchymal brain lesions were ascertained by a prospective, timed ultrasound scanning protocol in the first week of life. CP was ascertained at 2 years of age by clinical examination in 80% of survivors and by interview and medical record review in another 6% and was classified as disabling or nondisabling. RESULTS: No significant reduction in risk of nondisabling CP (adjusted odds ratio [OR], 1.00; 95% confidence interval [CI], 0.53 to 1.88) or disabling CP [DCP] (adjusted OR, 0.63; 95% CI, 0.32 to 1.24) CP with magnesium exposure was found in a logistic regression model that controlled for gestational age, fetal growth, gender, multiple birth status, mode of delivery, amnionitis, and hypertensive disorders. In a small subset of infants, those with onset of parenchymal lesions at 7 days of age or later (n = 29), magnesium exposure was associated with a significantly reduced risk of DCP (OR, 0.10; 95% CI, 0.02 to 0.65). Magnesium sulfate exposure was not associated with germinal matrix/intraventricular hemorrhage (adjusted OR, 0.89; 95% CI, 0.64 to 1.25) or with parenchymal brain lesions (adjusted OR, 0.83; 95% CI, 0.53 to 1.30). CONCLUSIONS: The hypothesis that magnesium sulfate use reduces the risk of neonatal brain lesions or CP in low birth weight infants was not statistically supported in this study, although a modest reduction in risk of DCP cannot be excluded. The data further suggest that magnesium exposure may be associated with reduction in risk of CP in low birth weight infants who have late-onset brain lesions, but this unpredicted observation requires confirmation in another data set.

Pediatric injury resulting from family violence.

OBJECTIVE: Children who live in violent households are at risk for emotional and physical injury. Although recent research has addressed the emotional impact of witnessing family violence, no study has addressed the inadvertent physical injuries that result to children who witness family violence. The objective of this study was to describe the causes, types, and patterns of pediatric injuries resulting from family violence. METHODS: We reviewed the medical records of 139 children who presented to the emergency department with injuries resulting from domestic violence for demographic information, mechanism of injury, type, location, and severity of injury, treatment, and disposition. RESULTS: Children who were injured during domestic violence ranged in age from 2 weeks to 17 years. Although the mean age of the children identified was 5 years, 48% of the children were younger than 2 years. Although the most common dyad involved in the fight was the mother and father (57% of cases), extended family members and nonrelated adults were involved in almost one third of the cases. The most common mechanism of injury was a direct hit (36%). Of the injured children who were younger than 2 years, 59% were injured while being held by parents. Thirty-nine percent of the children were injured during attempts to intervene in fights. The majority of injuries were to the head (25%), face (19%), and eyes (18%). Young children sustained more head and facial injuries than older children, who had disproportionately more extremity trauma. Medical intervention was indicated in 43% of patients, of which 9% required hospital admission and 2% required surgical or intensive care intervention. Of the 91% of children discharged from the emergency department, 73% returned home, and 27% went to alternative homes. CONCLUSIONS: Children sustain a wide range of physical injuries from family violence. Because the majority of injuries are minor, specific inquiry into the causes of all pediatric injuries may help further identify children living among family violence.

Neonatal cranial ultrasound abnormalities in low birth weight infants: relation to cognitive outcomes at six years of age.

OBJECTIVE: To assess the independent relation of neonatal cranial ultrasound (US) abnormalities in low birth weight (LBW) infants to cognitive outcomes at 6 years of age. DESIGN: Prospective cohort study. SAMPLE AND METHODS: Six-year follow-up data were obtained on a regional birth cohort of LBW infants (< 2 kg) systematically screened as neonates with serial US. US abnormalities were dichotomized into isolated germinal matrix/intraventricular hemorrhage (GM/IVH) and parenchymal lesions/ventricular enlargement (PL/VE). Global cognitive outcomes (mental retardation, borderline intelligence, and normal intelligence) and selected specific cognitive abilities were assessed at 6 years of age with standardized instruments. Multivariate techniques were used to assess the effects of US independent of maternal social disadvantage at birth and other perinatal and neonatal risk factors. RESULTS: The sample as a whole had a significantly elevated rate of mental retardation (MR; 5%), almost all moderate to profound in severity. PL/VE was independently related to MR (odds ratio [OR], 65.8; confidence interval [CI], 19.1 to 22.4) and borderline intelligence (OR, 3.7; CI, 1.3 to 10.8); isolated GM/IVH was more modestly related to MR (OR, 4.6; CI, 1.2 to 18.6) but not related to borderline intelligence. Approximately half of the cases of MR were attributable to PL/VE independent of other factors. Of non-US factors, the number of days receiving mechanical ventilation increased the risk for MR. Maternal social disadvantage increased the risk for borderline intelligence but not MR. Among children of normal intelligence, those with PL/VE, but not isolated GM/IVH, performed more poorly than those without US abnormalities on tests of visual perceptual organization but not on tests of language, memory, or quantitative skills. CONCLUSION: Prevention of white matter injury would substantially improve cognitive outcomes for LBW infants.

Vision outcome at age 2 years in a low birth weight population.

We assess the prevalence of vision problems in a cohort of low birth weight infants at age 2 years and the relationship of these problems to neonatal brain injury. Data on prenatal and neonatal history and brain injury status were prospectively collected on 721 children weighing 500-2,000 gm at birth enrolled in a multi-center, population-based longitudinal study. Visual acuity was evaluated using the Teller Acuity Card Procedure. Abnormalities of the eye were assessed by a specially trained pediatric nurse practitioner. Failure of the acuity screen occurred in 62 of 699 tested (8.9%). Multiple logistic regression analysis revealed that the only significant independent predictors of failure included presence of disabling cerebral palsy (DCP) (odds ratio [OR] = 14.8) or nondisabling cerebral palsy (NDCP) (OR = 4.0) and Apgar score of less than 5 at 5 minutes (OR = 2.4). Parenchymal brain injury (PEL) was of borderline significance. Strabismus was present in 123 of 702 children (17.5%). Multiple logistic regression analysis disclosed that the joint predictors of strabismus were presence of DCP (OR = 7.2) and length of hospital stay (OR = 1.6). We conclude that low birth weight infants with parenchymal brain lesions leading to cerebral palsy are at particular risk for vision problems early in life and should be carefully evaluated.

Blood pressure ranges in premature infants: II. The first week of life.

OBJECTIVE: To examine the arterial blood pressure in the first week of life in a healthy premature population. DESIGN: Population-based cohort study. SETTING: Three intensive care nurseries in central New Jersey. PATIENTS: Premature infants with birth weights less than 2000 g. MAIN OUTCOME MEASURES: We documented daily maximum and minimum systolic and maximum and minimun diastolic blood pressures during the first 7 days of life. To examine the effects on the ranges of blood pressure, we identified four groups of infants: (1) healthy infants without any of the major risk factors (n = 193); (2) infants who were mechanically ventilated but free of any of the other conditions (n = 225); (3) infants with histories of maternal hypertension or preeclampsia (n = 38) and (4) infants with low Apgar scores (less than 3 at 1 minute and less than 6 at 5 minutes) regardless of the presence of other conditions (n = 86). RESULTS: Blood pressure increased steadily in the first week of life in all four groups. There was no relationship between any of the four blood pressure variables, or trends in blood pressure over time, with birth weight, gender, or race. Regression equations (based on all infants with available data) for blood pressure ranges by day of life revealed that the maximum systolic blood pressure increased by 2.6 mm Hg/d, the minimum systolic blood pressure increased by 1.8 mm Hg/d,the maximum diastolic blood pressure increased by 2.0 mm HHg/d, and the minimum diastolic blood pressure increased by 1.3 Hg/d. CONCLUSIONS: Infants with birth asphyxia and ventilated infants had significantly lower systolic and diastolic blood pressures than healthy infants.

The relation of transient hypothyroxinemia in preterm infants to neurologic development at two years of age.

BACKGROUND: Transient hypothyroxinemia, a common finding in premature infants, is not thought to have long-term sequelae or to require treatment. We investigated whether hypothyroxinemia in premature infants is a cause of subsequent motor and cognitive abnormalities. METHODS: In this historical cohort study, we retrieved blood thyroxine values, obtained on routine screening in the first week of life, from state screening records on children who weighted 2000 g or less at birth, who were born at 33 weeks' gestation or earlier, and who were enrolled in a population-based study of the late sequelae of neonatal brain hemorrhage. We investigated the relation of these values to the odds for disabling cerebral palsy among 463 subjects for whom data were available and to the mental-development score on the Bayley Scales of Infant Development or the Stanford-Binet Intelligence Scales for Children at the age of two years in 400 subjects. The effects of severe hypothyroxinemia, defined as a blood thyroxine value more than 2.6 SD below the mean for New Jersey newborns, were assessed before and after adjustment for gestational age and potentially confounding variables. RESULTS: In analyses adjusted for gestational age, infants with severe hypothyroxinemia had a risk of disabling cerebral palsy that was nearly 11 times that of infants without hypothyroxinemia (odds ratio, 10.8; 95 percent confidence interval, 3.0 to 39.3) and a mean mental-development score at the age of two that was 15.4 points lower (95 percent confidence interval, 8.1 to 22.6 points) than the mean score of children with normal neonatal blood thyroxine concentrations. After adjustment for gestational age and multiple prenatal, perinatal, and early and last neonatal variables, severe hypothyroxinemia was still associated with an increased risk of disabling cerebral palsy (odds ratio, 4.4; 95 percent confidence interval, 1.0 to 18.6) and a reduction of nearly 7 points (95 percent confidence interval, 0.3 to 13.2 points) in the mental-development score. CONCLUSIONS: Severe hypothyroxinemia in preterm infants may be an important cause of problems in neurologic and mental development detected at the age of two years.

Longitudinal assessment for lead poisoning.

In a previous study, we showed that in our region the prevalence of lead poisoning (Pb > or = 10 micrograms/dL [0.483 mumol/L]) was high (29%) among urban infants. The objectives of this study were to assess the prevalence of lead poisoning over time in this cohort to determine the best screening strategy. Eighty-nine percent (115/129) of infants who were initially screened for lead poisoning between 6 and 12 months of age had a repeat venous lead level by age 3 years (mean = 19.8 months). The majority (70%) lived in a major city and had private medical insurance (80%). The initial and repeat mean venous lead levels were similar for the overall population (lead1 = 8.7 micrograms/dL +/- 6.2 [0.420 +/- 0.299 mumol/L] and lead2 = 7.7 micrograms/dL +/- 6.8 [0.371 +/- 0.328 mumol/L]). However, the percentage of lead-poisoned (Pb > or = 10 micrograms/dL or 0.483 mumol/L) children whose levels were > or = 15 micrograms/dL (0.724 mumol/L) increased from 28% to 48% on repeat. The utility of the initial screen in predicting a second elevated lead level > or = 20 micrograms/dL (0.966 mumol/L) was as follows: sensitivity = 33%, specificity = 97%, positive predictive value = 40%, negative predictive value = 96%. We conclude that in this population, a single screen at 18-24 months of age would reduce the need for multiple venipunctures and would detect those children in need of an intervention.

Phenylketonuria screening: effect of early newborn discharge.

OBJECTIVE: To determine the percentage of term newborns discharged by 24 hours of life and the actions taken by physicians and institutions to avoid false-negative phenylketonuria (PKU) screens in these infants. DESIGN: Descriptive cross-sectional survey. PARTICIPANTS: One hundred forty term nurseries and 157 pediatricians. SELECTION PROCEDURE: Stratified sampling techniques were used to sample nurseries from the 1992 American Hospital Association guide to provide equal representation of each region of the country. Pediatricians were systematically sampled from a national list of practicing pediatricians supplied by Ross Laboratories to provide equal sampling from each state. RESULTS: The response rates were 95% (n = 133) for term nurseries and 83% (n = 131) for pediatricians. Twenty-four percent of healthy newborns are discharged by 24 hours of life. Ninety-three percent of nurseries screen all infants for PKU before discharge. In states without laws mandating rescreening, only 48% of institutions that discharge the majority of their infants (> 50%) by 24 hours of life rescreen. Also, in states without rescreening laws, 64% of pediatricians rescreen. The timing of this repeat screen ranges from less than 72 hours of life to 4 weeks. Determining which infants to rescreen varies by practitioner; some rescreen all infants, whereas others rescreen those discharged early. Just more than half of all pediatricians, whether practicing in a state requiring repeat PKU screening, claim to be familiar with the American Academy of Pediatrics recommendations regarding repeated PKU screening of infants discharged by 24 hours of life. CONCLUSION: Twenty-four percent of term newborns in the United States are discharged by 24 hours of life. Most hospitals screen all infants for PKU before discharge regardless of age. The majority of states do not mandate rescreening; rescreening policies among pediatricians and institutions in those states vary widely. A significant number of infants do not receive repeated screening and are therefore at risk for delayed or missed diagnosis of PKU because of insensitive initial screens. Pediatrician awareness of the need to perform repeated PKU screens on infants discharged by 24 hours is poor.