Agnes Perenyi

Development of Localized Pulmonary Interstitial Emphysema in a Late Preterm Infant without Mechanical Ventilation

Pulmonary interstitial emphysema (PIE) is not an uncommon finding in premature infants with respiratory distress who need respiratory support by mechanical ventilation. PIE has been reported in a few cases of neonates in whom either no treatment other than room air was given or they were given continuous positive end-expiratory pressure (CPAP) support. We present a case of a premature neonate who presented with respiratory distress, in whom PIE and spontaneous pneumothorax (PTX) developed while on CPAP therapy only. The patient was treated conservatively with subsequent resolution of the radiological findings and clinical improvement. No surgical intervention was required. It is important to know that PIE may develop independently of mechanical ventilation. We would like to add this case to the literature and describe the pertinent plain film and computed tomography (CT) findings of this entity, the possible mechanism of development, and the differential diagnosis. A review of the literature is also provided.

Analysis of compliance, morbidities and outcome in neurodevelopmental follow-up visits in urban African-American infants at environmental risk.

The objectives of this study were to determine compliance rate in a uniform, urban African-American patient population at environmental risk for adverse neurodevelopmental outcome and to define risk factors for non-compliance with neurodevelopmental follow-up. A retrospective chart review was performed which included 481 infants with birth weight (BW) of 495-4195 g and gestational ages (GAs) between 23 and 42 weeks born at our hospital. Statistical analysis was performed using the Jonckheere-Terpstra test for ordinal variables. For 2 × 2 tables, χ 2 test and Fishers exact test (P < 0.05) were used. To determine significant predictive variables, data were analyzed by multiple logistic regression with one independent variable at a time. Infants compliant with follow-up had significantly more morbidities in the very low BW category (⩽1500 g) than infants with larger BW. The highest compliance rate (70%) was found among the smallest and most immature (GA ⩽28 weeks) infants. Based on this finding, we postulate that the number of infants with severe disability is not likely to be underestimated. The significantly more frequent developmental anomalies found in the largest BW (⩽2500 g) category raises significant concern, though findings in this subset of infants may not be representative of the whole population. There was no significant difference between the compliant and non-compliant groups regarding socio-economic status. Severe or multiple morbidities and prolonged hospital stay may provide parents with greater opportunity to learn and understand about the infants condition which may lead to greater compliance.

The role of folate receptor autoantibodies in preterm birth

OBJECTIVE Cellular uptake of folate is mediated by folate receptor (FR)α. Prior studies indicate that a FRα autoantibody (FRAb) is implicated in poor pregnancy outcomes. The aims of this study were to determine the prevalence of FRAbs in women with preterm and term pregnancies, and to investigate the role of maternal FRAbs in preterm birth. METHODS This prospective observational study included 23 mothers and 25 preterm infants (two twin births) born at gestational age (GA) ≤32 wk and/or birth weight ≤1500 g (group 1) and 25 mother-term infant pairs (infants born at GA ≥37 wk, group 2). Blocking and binding FRAbs in maternal and in cord blood were determined. The association between maternal FRAbs and pregnancy outcome was measured using multiple logistic regression, adjusted for maternal age and previous preterm birth. RESULTS The prevalence of FRAbs was 65.2% in women with preterm birth, which was twofold higher than in those with term pregnancy (28%; relative risk [RR], 2.3; 95% confidence interval [CI], 1.2-4.7). The prevalence of FRAbs in preterm infants (64%) was significantly higher than in term infants (24%; RR, 2.7; 95% CI, 1.3-5.7). Pregnant women with positive FRAbs had 4.9 times higher odds of having preterm birth (odds ratio, 4.9; 95% CI, 1.4-17.7), adjusted for maternal age and previous preterm birth. CONCLUSIONS These findings suggest that the presence of FRAbs might be a contributing factor to preterm birth, which could be prevented with appropriate testing and therapeutic interventions. Further studies are warranted to investigate the possible mechanisms of fetal sensitization resulting in FRAb production in utero and its possible clinical correlates.

Neurodevelopmental outcome and risk factors for impaired development of African American infants in an underserved urban population: a population-based study.

We aimed 1) to define risk factors for adverse outcome in urban African American patients, 2) to determine whether clinical variables as risk factors are congruent with previously published data, and 3) to identify the proportion of infants with different outcomes. The study included African American infants who were born and participated in neurodevelopmental follow-up. Infants with gestational age range of 23 to 41 weeks, and birth weight (BW) range of 495 to 3,965 g were classified by developmental outcome. Among the smallest infants, BW, gestational age, gender and respiratory distress syndrome were significantly (p<.05) associated with adverse outcome. No significant risk factors were identified for adverse outcome in the two other birth weight categories. Adverse outcomes were seen more frequently in infants with BW ≤1,500 g than in larger infants. The number of infants with severe outcome was found higher than previously reported and may be related to different racial/generational origin.

Clinical utility of corpus callosum measurements in head sonograms of preterm infants: a cohort study

Objective To assess the clinical usefulness of measurement of corpus callosum (CC) size in head ultrasound (HUS) to predict short-term neurodevelopmental (ND) outcomes in preterm infants. We hypothesised that including CC measurements in routine HUS will be an additional tool for early identification of infants at risk of adverse short-term ND outcome, over and above the predictive power of perinatal morbidities. Design Retrospective cohort study. Setting Level III neonatal intensive care unit (NICU) and outpatient NICU follow-up clinic of an academic medical centre in New York City. Participants 929 HUS of 502 infants with gestational age of 23–36 weeks in African-American infants were initially studied. Exclusion criteria included those who died, had gross abnormalities in HUS, infants with race other than African-American, infants with suboptimal quality of HUS, late preterm infants and infants who did not participate in ND follow-up. A total of 173 infants completed the study. Interventions CC size (length and thickness) was measured in a subset of 87 infants who had routine HUS between 23 and 29 weeks (0–6 postnatal weeks). Relevant clinical variables were collected from chart reviews. ND assessments were completed in outpatient follow-up clinics. A statistical model was developed to assess the clinical utility and possible predictive value of CC measurements for adverse short-term ND outcome, while adjusting for perinatal morbidities. Primary and secondary outcome measures CC size and ND status. Results Measurements of CC size did not add substantial predictive power to predict short-term ND outcome beyond the information provided by the presence of morbidities related to prematurity. Conclusions No association was found between morbidities related to prematurity and short-term ND outcome and CC size in preterm infants. CC measurements in HUS early in life did not have an additional value in predicting short-term ND outcome, therefore did not seem to provide further clinical utility.

The Influence of Dosage and Timing of Caffeine Administration on Neurodevelopmental Outcome of Very Preterm Infants

Objective: To analyze starting time (early versus late) and duration of caffeine treatment and its possible influence on neurodevelopmental (ND) outcome in very preterm infants. Hypothesis: Early initiation of caffeine treatment with longer duration of treatment may significantly improve ND outcome in very preterm infants. Design: Retrospective cohort study. Setting: Level III Neonatal Intensive care Unit (NICU) and out-patient NICU follow-up clinic of an academic medical center in New York City. Participants: A total of 146 inborn infants with gestational ages (GA) of 23-32 weeks who received caffeine treatment were included in this study with the following exclusion criteria: incomplete clinical data, insufficient ND follow-up and transfer of infants to other facilities. Interventions: Information on the administration of Caffeine Citrate injection USP and Caffeine Citrate oral solution (20 mg/ml equivalent to 10 mg caffeine base) including duration of treatment were obtained from individual chart reviews. Primary outcome measure: Normal and adverse (mild/moderate, severe) ND outcome. Results: Duration and starting point (early versus late) of caffeine treatment were not associated with ND outcome; adjusted for GA, head ultrasound (HUS) results and gender. The only significant predictor of ND outcome was GA. Conclusion: Gestational age (GA) seems to have more of an influence on ND outcome than caffeine citrate treatment regardless of duration (i.e., dose) and onset (early versus late) of such treatment.

Interrater and Intrarater Reliability Using Prechtl's Method of Qualitative Assessment of General Movements in Infants

Purpose: To establish interrater and intrarater reliability of two novice raters (the two authors) with different educational background in assessing general movements (GM) of infants using Prechtl’s method. Methods: Forty-three infants under 20 weeks of post-term age were recruited from our Level III neonatal intensive care unit (NICU) and NICU follow-up clinics of our medical center. The infants were observed using the GM assessment either during the writhing movement or the fidgety movement age periods. Results: There was no significant difference (p > 0.05) between the two observers on interrater reliability and between Trials 1 and 2 for interrater reliability. Conclusion: Novice raters need to establish their interrater and intrarater reliabilities in order to correctly identify GM patterns. The ability to correctly identify GM patterns in infants may be influenced by the raters’ varying educational background. The infant’s GMs as gross motor movements are called writhing movements (WMs) which are preceded by variable preterm GMs before 36weeks. WMs can be observed after birth in both term and preterm infants. These GMs involve the whole body in variable sequence of the neck, trunk and extremities. They are described by Prechtl as “complex, elliptical, fluent, and are of moderate to large amplitude, with an intensity, force and speed that increases and decreases over time” [12]. The same GMs observed in preterm infants are frequently observed as WMs with faster speed and larger amplitude. If the GMs appear as monotonous and less complex, they are referred to as poor repertoire (PR) movements [12].