***ECD*** maternal C-reactive protein as a predictor of neonatal sepsis.

Systemic bacterial infection in the newborn has a significant impact on neonatal mortality and morbidity. Non-invasive prenatal markers of risk could be useful in the prediction and prevention of neonatal sepsis. We evaluated the association of maternal third-trimester serum level of C-Reactive Protein (CRP) with neonatal sepsis in a sample of infants in the JAKids pregnancy and birth cohort study. A population-based nested case-control design was used to identify cases and controls of neonatal sepsis from the subset of infants in the JAKids study whose mothers had serum archived in the early third trimester and who were admitted to newborn intensive care. Cases were 25 neonates with neonatal sepsis identified from hospital records. Controls were a random sample of 62 sepsis-free neonates matched to cases within three gestational age strata - ≤32 weeks, 33-36 weeks, and ≥37 weeks.Mothers of neonatal sepsis cases ≥37 weeks had significantly higher mean levels of maternal CRP protein than mothers of controls (11.0 mg/dL ± 3.0 vs. 8.7 mg/dL ± 5.9; p < .05). Differences in maternal CRP were not found in sepsis cases born ≤32 weeks (9.5 mg/dL ± 4.2 vs 5.8 mg/dL ± 4.0, p = .23) nor in sepsis cases born at 33-36 weeks (9.0 mg/dL ± 3.6 vs 11.9 mg/dL ± 7.8, p = .34). Maternal third-trimester C-reactive protein levels were elevated in mothers of term-born neonates with sepsis, but not in the mothers of preterm neonates with sepsis.

Psychopathology in young adults born at extremely low birth weight.

BACKGROUND: Little is known about the long-term mental health of extremely low birth weight (ELBW) (<1000 g) survivors. We test whether young adults aged 22 to 26 years born at ELBW differ from normal birth weight (NBW) controls in self-reported levels of psychopathology. METHOD: Participants included 142 ELBW survivors (86% response) born between 1977 and 1982 to residents of central-west Ontario, Canada and 133 NBW control subjects (92% response). The Young Adult Self-Report measure was used to create five DSM-IV oriented scales aggregated to form internalizing (depressive problems, anxiety problems, avoidant personality problems) and externalizing (attention deficit-hyperactivity disorder problems and antisocial personality problems) scales. RESULTS: After adjusting for family background characteristics, mean scores for ELBW survivors were 3.02 [95% confidence interval (CI) 0.78-5.26] points higher for internalizing problems and no different, i.e. 0.00 (95% CI -1.17 to 1.17), for externalizing problems. There was a sex × group statistical interaction such that being male muted the risk for externalizing problems among those born at ELBW: -2.11 (95% CI -4.21 to -0.01). Stratifying ELBW adults as born small for gestational age (SGA) versus appropriate weight for gestational age (AGA) revealed a significant gradient of risk for levels of internalizing problems that was largest for SGA, i.e. 4.75 (95% CI 1.24-8.26), and next largest for AGA, 2.49 (95% CI 0.11-4.87), compared with NBW controls. CONCLUSIONS: Depression, anxiety and avoidant personality problems (internalizing problems) are elevated in young adulthood among ELBW survivors. This effect is relatively small overall but noticeably larger among ELBW survivors born SGA.

Differential methylation of insulin-like growth factor 2 in offspring of physically active pregnant women.

Several studies have suggested that maternal lifestyle during pregnancy may influence long-term health of offspring by altering the offspring epigenome. Whether maternal leisure-time physical activity (LTPA) during pregnancy might have this effect is unknown. The purpose of this study was to determine the relationship between maternal LTPA during pregnancy and offspring DNA methylation. Participants were recruited from the Archive for Research on Child Health study. At enrollment, participants' demographic information and self-reported LTPA during pregnancy were determined. High active participants (averaged 637.5 min per week of LTPA; n=14) were matched by age and race to low active participants (averaged 59.5 min per week LTPA; n=28). Blood spots were obtained at birth. Pyrosequencing was used to determine methylation levels of long interspersed nucleotide elements (LINE-1) (global methylation) and peroxisome proliferator-activated receptor-gamma (PPARγ), peroxisome proliferator-activated receptor-gamma coactivator (PGC1-α), insulin-like growth factor 2 (IGF2), pyruvate dehydrogenase kinase, isozyme 4 (PDK4) and transcription factor 7-like 2 (TCF7L2). We found no differences between offspring of high active and low active groups for LINE-1 methylation. The only differences in candidate gene methylation between groups were at two CpG sites in the P2 promoter of IGF2; the offspring of low active group had significantly higher DNA methylation (74.70±2.25% methylation for low active v. 72.83±2.85% methylation for high active; P=0.045). Our results suggest no effect of maternal LTPA on offspring global and candidate gene methylation, with the exception of IGF2. IGF2 has been previously associated with regulation of physical activity, suggesting a possible role of maternal LTPA on regulation of offspring physical activity.

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.

Groups of histopathologic abnormalities in brains of very low birthweight infants.

The neuropathologic changes in brains of very premature infants are well recognized but relatively few studies have attempted to identify if specific neuropathologic features cluster together. These data could assist in determining pathogenetic mechanisms of immature brain injury. The goal of this study is to identify which, if any, combinations of histologic features occur together. We identified the presence or absence of 19 histologic features in the brains of 67 infants from a multicenter study of 1,665 prematurely born infants whose birthweight was 500-1,500 grams. We used clustering algorithms and factor analysis to group pathologic features that occurred together. Our results indicate that certain histopathologic features do cluster. For example, telencephalic white matter astrocytosis occurs in 2 groups: 1) associated with amphophilic globules, and, 2) in an uncorrelated group, associated with focal macrophage deposits and coagulative necroses. Parenchymal hemorrhage was not found to be associated with any telencephalic leukoencephalopathy, regardless of whether characterized by rarefaction, astrocytosis, focal coagulative necroses, or foci of macrophages in the white matter. Intraventricular hemorrhage and germinal matrix hemorrhage were not seen together more often than by chance expectation. Intraventricular hemorrhage was only marginally associated with parenchymal hemorrhage. Our data indicate that specific histopathologic features tend to preferentially cluster with each other in groups. This clustering may represent the manifestation of a common mechanism for each. These data should be valuable indicators for future research attempting to establish pathogenesis.

Emergency room utilization in the first 15 months of life: a randomized study.

The impact of a system of primary pediatric care on emergency room use in a municipal hospital was measured by comparing that use in two randomly selected populations. The population that was offered participation in a primary care program consistently used the emergency room less than did the control group. Analysis of the pattern of utilization revealed that the differences were limited to patients who actually participated in the program, and to weekday use of the emergency room. Unusually heavy (greater than ten visits per year) use of the emergency room was virtually eliminated among participants in the primary care program.

Impact of improved survival of very low birth weight infants on recent secular trends in the prevalence of cerebral palsy.

OBJECTIVE: To review recent secular trends in the prevalence of cerebral palsy in industrialized countries that have population-based cerebral palsy registries and to estimate such time-trends for the United States, where until recently such registries were absent. DATA SOURCES: Recent epidemiologic studies of cerebral palsy published in peer-reviewed journals in English, and US vital data bearing on the principal demographic determinants of cerebral palsy--birth rates, the birth weight distributions, birth weight-specific mortality risk, and cerebral palsy risk among survivors. RESULTS: Most epidemiologic studies from industrialized countries show a rise in the childhood prevalence of cerebral palsy in recent decades, largely because of the increasing contribution of children of low and very low birth weight to its prevalence. The only demographic determinant of cerebral palsy prevalence that is changing rapidly in the United States is survival of low birth weight and very low birth weight infants. Based on the magnitude of change in the survival of low and very low birth weight infants, it is estimated that childhood prevalence of cerebral palsy rose about 20% between 1960 and 1986 in the United States. CONCLUSION: An apparently unavoidable side effect of the increasing success of newborn intensive care is a moderate rise in the childhood prevalence of cerebral palsy.

Age at death used to assess the effect of interhospital transfer of newborns.

In New York City, newborn units classified as level 1 (no intensive care) frequently transfer low-birth-weight infants to units classified as level 3 (complete intensive care), but level 2 units (those with intermediate levels of care) transfer rarely. As deaths occurring in the first hours of life are unlikely to be affected by infant transport services, early (first four hours), late (four hours to 28 days), and overall neonatal death rates were separately examined at each of the three levels of care for singleton live-births weighing 501 to 2,250 g. As previously reported, overall neonatal mortality (adjusted for birth weight, gestational age, sex, and race) for births at level 1 units (163.0/1,000) and level 2 units (168.1/1,000) was similar, and rates for births at level 3 (128.0/1,000) were significantly lower. Mortality up to four hours, and from four hours to 28 days, however, differed between level 1 and level 2 units. Among early deaths, the mortality for level 1 births was 68.0/1,000, significantly higher than both the rate for level 2 births (46.0/1,000) and for level 3 births (40.6/1,000). Between four hours and 28 days, mortality relative to level 3 improved for level 1 births, but worsened for level 2 births. For infants with birth weight less than 1,251 g, for whom transport rates from level 1 units are highest, mortality in level 1 births was higher than in level 2 births only until 18 hours of life; thereafter, level 2 mortality was higher.(ABSTRACT TRUNCATED AT 250 WORDS)

Perinatal brain injury in premature infants born to mothers using alcohol in pregnancy. Neonatal Brain Hemorrhage Study Team.

OBJECTIVE: Alcohol has been shown to have teratogenic effects on the fetal central nervous system. However, little research has been done to assess the impact of prenatal alcohol exposure on premature infants, a group particularly vulnerable to perinatal brain injury. METHODS: We examined the relation between maternal alcohol use and the most common forms of brain injury in premature infants--germinal matrix/intraventricular hemorrhage (GM/IVH) and white-matter damage--in a large population-based cohort of infants weighing 2000 g or less. The analyses included 349 infants younger than 31 weeks' gestation who received at least one cranial ultrasound scan and whose mothers were queried about prenatal alcohol use in a postpartum interview. RESULTS: Infants of mothers who reported "moderate" alcohol use (fewer than seven drinks per week and fewer than three drinks per occasion) to "high" use (seven or more drinks per week and/or three or more drinks per occasion) before recognized pregnancy, and moderate alcohol use during pregnancy, were not at increased risk for brain injury. However, after controlling for potentially confounding factors, infants of women reporting high alcohol use during pregnancy were at increased risk of developing isolated brain hemorrhage (odds ratio [OR] = 5.5, 95% confidence interval [CI] = 1.2, 24.7), any brain hemorrhage (OR = 6.7, 95% CI = 1.8, 26.4), and white-matter damage (OR = 9.5, 95% CI = 1.9, 46.4). CONCLUSION: Premature infants of women who report consuming seven or more drinks per week and/or three or more drinks per occasion during pregnancy have substantially elevated risks of both of the most common forms of brain injury in premature infants.

Cranial ultrasound prediction of disabling and nondisabling cerebral palsy at age two in a low birth weight population.

OBJECTIVE: To employ multivariate analytic techniques to assess the association between neonatal cranial ultrasound (US) abnormalities and subsequent cerebral palsy (CP), defined as disabling CP (DCP) or nondisabling CP (NDCP) depending on the level of motor dysfunction. DESIGN: Prospective cohort study. SUBJECTS AND METHODS: The Neonatal Brain Hemorrhage Study enrolled a geographically representative sample of 1105 newborns 501 to 2000 g and obtained follow-up data on 777 (86%) of the 901 survivors at age two. One hundred thirteen children (14.6%) had motor findings severe enough to classify them as having CP. The 61 (7.9%) of these children who were disabled by their motor impairment we classified as having DCP. The remaining 52 (6.7%) who had definite neurologic findings (usually mild spastic diplegia) but without evidence of interference with daily living, we classified as having NDCP. RESULTS: In a multivariate logistic regression model of perinatal and postnatal variables, the following factors were found to be significant risk factors for DCP: parenchymal echodensities/lucencies or ventricular enlargement (PEL/VE) on cranial US (OR = 15.4; 7.6, 31.1), germinal matrix/intraventricular hemorrhage (GM/IVH) (OR = 3.5; 1.7, 6.9) and mechanical ventilation (OR = 2.9; 1.2, 7.1). Fully 93.4% of infants were correctly classified as to presence or absence of DCP on the basis of this model. Birth weight, gestational age, length of hospital stay, gender, race, plurality, presence of labor and Apgar score were not significant independent predictors of DCP. For NDCP, the only risk factor significant in the multivariate model was PEL/VE (OR = 5.3; 2.2, 12.6). CONCLUSIONS: Among perinatal and postnatal factors, cranial US abnormalities are by far the most powerful predictors of disabling CP in low birth weight infants. Although PEL/VE was the strongest predictor, GM/IVH also appeared to independently contribute to the risk of DCP. NDCP in low birth weight infants appears to have a different risk profile than DCP. In particular, it is less closely related to US evidence of perinatal brain injury.

Medical care and preterm infants of normal birth weight.

Preterm infants of normal birth weight (born before 37 completed weeks of gestation and weighing more than 2,250 g) experience a neonatal mortality risk almost four times higher than do term infants in the same weight range. In an analysis of the effect of hospital level of birth on neonatal mortality, such preterm normal weight infants were found to experience higher mortality if born outside of a Level 3 (tertiary care) center. For all singleton infants in this weight-gestation category born in New York City maternity services during a 3-year period (N = 23,257), the relative mortality risk for Level 1 births (compared with Level 3) was 1.72 (P less than .01) and for Level 2 births 1.47 (P less than .05). The excess mortality at Level 1 and Level 2 units was almost entirely due to a more than twofold higher death rate in black infants born in these units. Several potentially confounding socioeconomic, demographic, and biologic variables entered into a logistic regression model could not account for the higher mortality rates for black infants born in Level 1 and Level 2 units. Among black infants born at Level 1 units, deaths in preterm normal birth weight infants were less likely to occur in a receiving tertiary care center than were either deaths in low birth weight infants or deaths in term normal weight infants, suggesting that the need for special care of preterm normal birth weight infants is underestimated in some hospitals without newborn intensive care units.

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.

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.

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.

Neurobehavioral effects of power-frequency electromagnetic fields.

Some laboratory experiments have suggested that power-frequency electric and magnetic fields (EMF) may be capable of influencing calcium efflux from cell membranes, pineal function, and circadian rhythms. As yet, however, no consistent, replicable laboratory model has been developed for any of these effects. Most assessments of human volunteers exposed to EMF have been negative, but occasional effects on vigilance or alertness and some modest effects on circadian rhythmicity have been reported. Several carefully performed studies of workers occupationally exposed to high electric-field strengths have failed to find effects on behavior or cognitive functioning. Although the bulk of human research on the effects of EMF on cognitive performance is negative, there has been less assessment of behavior and psychiatric symptomatology. Because some studies, in both humans and animals, have described effects of EMF on circadian rhythms, future research might concentrate profitably on the assessment of EMF in relation to depression and other cyclically mediated psychiatric disorders.

The reliability of neonatal head circumference measurement.

Interobserver reliability in head circumference measurement was assessed in a cohort of 1105 low birthweight (less than or equal to 2000 g) infants enrolled in a study of brain hemorrhage. In 927 (83.9%) subjects, head circumference was measured both by a pediatric resident or admitting pediatrician, and by a trained ultrasound technologist. The Pearson correlation coefficient for these two sets of measurements was 0.934 (p less than 0.01), and the intraclass correlation coefficient was 0.933. By contrast, analysis of differences revealed that the limits of agreement were from -1.99 to 2.03 cm, indicating that 5% of measurements differed by 2 cm or more. Using clinicians' measurements as the gold standard, ultrasound technologists detected abnormal head circumferences with a sensitivity of 91.2%, a specificity of 97.2%, and a positive predictive value of 88.0%. For clinical purposes this level of reliability may be acceptable, but in research studies this degree of misclassification would lead to attenuation of the odds ratio.

Measuring health status using the Health Utilities Index: agreement between raters and between modalities of administration.

The aim of this study was to evaluate interrater and intermodality agreement in assessing health status using the Health Utilities Index. A random sample from a Dutch cohort of 14-year-old Very Low Birth Weight children and their parents were invited to participate in a face-to-face (n = 150) or telephone (n = 150) interview. All 300 participants were also sent a questionnaire by mail. Response rate was 68%. Interrater and intermodality agreement were high for the physical HUI3 attributes and poor for the psychological attributes. Children and parents reported more dysfunction in the psychological attributes when interviewed than when completing the mailed questionnaire. High agreement on the physical attributes may have resulted from the fact that hardly any dysfunction was reported in these attributes, and poor agreement in the psychological attributes may have been a result of the fact that in these attributes much more dysfunction was reported. In measuring children's health status using the HUI3, the results and their interpretation vary with the source of information and the modality of administration. For maximum comparability between studies, written self-report questionnaires seem the preferred option.

A quantitative review of mortality and developmental disability in extremely premature newborns.

OBJECTIVES: To summarize the literature on mortality rates and prevalences of major neurodevelopmental disabilities and to examine trends of these outcomes over time in extremely premature neonates. DATA SOURCES: MEDLINE was used to search the English literature for studies published since 1970 reporting on both mortality and disability in infants born at or before 26 weeks' gestation (extremely immature [EI] cohort), with a birth weight of 800 g or less (extremely small [ES] cohort), or subgroups of these. STUDY SELECTION: Studies were included in the analysis if all of the following were reported: mortality; direct examination of 75% or more of the survivors; and the proportion of patients with at least 1 of the following disabilities: cerebral palsy, mental retardation, blindness, and deafness. Studies reporting cohorts included as a subset of cohorts in another study were excluded. Forty-two studies providing mortality and disability data for 20 cohorts of 4116 EI infants and 38 cohorts of 4345 ES infants born after 1972 met the inclusion criteria. DATA EXTRACTION: Data were abstracted from all studies that met these criteria by two of us (J.M.L. and D.E.W.), independently; the data were then cross-checked to ensure accuracy. RESULTS: Survival averaged 41% for EI infants and 30% for ES infants, and it increased significantly with time. In contrast to mortality, the prevalences of major neurodevelopmental disabilities among survivors have not changed over time. The most common major disability was mental retardation, found in 14% of EI and ES survivors. Cerebral palsy was found in 12% of EI survivors and 8% of ES survivors, blindness was found in 8% of EI and ES survivors, and deafness was found in 3% of EI and ES survivors. Overall, 22% of EI survivors and 24% of ES survivors were classified as having at least 1 major disability. Each 100 EI or ES livebirths yielded 7 children with major disabilities; this prevalence was correlated with survival across cohorts. CONCLUSIONS: The prevalence of disabilities had not changed among EI or ES survivors with increasing survival. However, increasing survival of these infants has resulted in a steadily increasing prevalence of children with disabilities.

Antecedents and neonatal consequences of low Apgar scores in preterm newborns: a population study.

BACKGROUND: To examine the antenatal and early neonatal correlates of low Apgar scores (<3 and <6 at 1 and 5 minutes) in preterm newborns (23-34 weeks' gestation). OBJECTIVE: The use of Apgar scoring for premature newborns remains widespread, despite controversy regarding its reliability as a measure of morbidity and mortality in the neonatal period. DESIGN: A cohort of 852 preterm newborns born during a 34-month period between 1984 and 1987 was studied. Newborns were stratified into 2 groups by gestational age (23-28 weeks and 29-34 weeks), and data were analyzed, controlling for gestational age in single weeks. SETTING: Two academic and 1 community hospital, which together accounted for 83% of all preterm births in a tri-county area of central New Jersey during the study period. PATIENTS: All premature newborns (birth weight <2000 g and gestational age <35 weeks) born in the participating hospitals during the study period were evaluated. MAIN OUTCOME MEASURES: Antecedents included maternal illness during pregnancy, maternal complications of labor and delivery, and fetal heart rate abnormalities during labor and delivery. Consequences included delivery room resuscitation, abnormal physical findings, diagnoses, and therapeutic interventions in the first 6 to 8 hours of life. RESULTS: Premature newborns with low Apgar scores received more cardiopulmonary resuscitation in the delivery room and in the first 6 to 8 hours of neonatal intensive care. Mortality was significantly increased among newborns with low Apgar scores (54% vs. 26% in the 23- to 28-week stratum, 30% vs 6% in the 29- to 34-week stratum). Newborns with low Apgar scores in the 29- to 34-week stratum more often required intubation, positive pressure ventilation, and umbilical vessel catheterization. Newborns with low Apgar scores had higher rates of bradycardia, pneumothoraces, acidosis, and increased oxygen requirement during the first 6 to 8 hours of life. Maternal illness, complications of labor and delivery;, and fetal heart rate decelerations did not correlate with subsequent Apgar scores of newborns. The presence of severe bradycardia (<90/min) and fetal heart rate accelerations correlated with low Apgar scores in the 29- to 34-week group. CONCLUSION: Low Apgar scores are associated with increased neonatal morbidity and mortality in preterm newborns. Antenatal maternal history, and pregnancy complications are not clearly associated with low Apgar scores. Therefore, the Apgar score is a useful tool in assessing neonatal short-term prognosis and the need for intensive care among preterm newborns.

Sonographic diagnosis of cisternal subarachnoid hemorrhage in the premature infant.

PURPOSE: To evaluate sonographic criteria for the diagnosis of subarachnoid, and particularly cisternal, hemorrhage in the preterm infant. METHODS: The subarachnoid cisterns were studied on cadaveric anatomic sections and on postmortem ultrasonograms, as well as on in vivo ultrasonograms of healthy neonates. Based on the normal ultrasound appearances of these cisterns, criteria were developed for the recognition of abnormal cisternal fluid collections, which strongly suggest the presence of subarachnoid hemorrhage in the premature infant. These criteria were evaluated prospectively in a group of 63 preterm infants who underwent subsequent autopsy. RESULTS: In the 63 infants with neuropathologic verification, increased echogenicity and/or increased echo-free content of the subarachnoid cisterns correctly predicted subarachnoid hemorrhage with an accuracy of 75%, sensitivity of 69%, and specificity of 93%. The positive and negative predictive values were 97% and 46%, respectively. In 47% of the cases, ultrasound correctly detected cisternal subarachnoid hemorrhage before intraventricular hemorrhage could be diagnosed. CONCLUSION: A highly specific, although somewhat insensitive, sonographic diagnosis of subarachnoid hemorrhage can be made from the appearance of the subarachnoid cisterns. The diagnosis of subarachnoid hemorrhage may predate the ultrasound diagnosis of intraventricular hemorrhage and may alert the neonatologist to the need for follow-up sonograms in the absence of ultrasound evidence of intraventricular hemorrhage.