Albert Martijn

Qualitative assessment of general movements in high-risk preterm infants with chronic lung disease requiring dexamethasone therapy.

OBJECTIVE The objective of this study was to determine in preterm infants at risk for severe chronic lung disease (1) the quality of general movements (GMs) and (2) the effect of dexamethasone treatment on spontaneous motor activity. STUDY DESIGN In 15 very low birth weight infants the quality of GMs was assessed from repeated videotape recordings. Recordings were made at weekly intervals during the preterm period until term age and thereafter three times until the twentieth postterm week. All infants required dexamethasone therapy, and additional recordings were made a few hours before and 24 hours, 48 hours, and 7 days after dexamethasone was started. The relationship among movement quality, brain ultrasonographic abnormalities, and long-term outcome was explored. Acute effects of dexamethasone on motor activity were examined. RESULTS After dexamethasone therapy was started, a significant transient reduction of the quantity of most spontaneous movements (p < 0.05) and a reduction of speed and amplitude of GMs was found (p < 0.05). A significant relationship was found between the severity of brain ultrasonographic abnormalities and the extent to which developmental trajectories of GMs were abnormal (p < 0.001). The development of cerebral palsy was related to the presence of cramped-synchronized movements near term (p < 0.02) and to the absence of fidgety movements at the age of 3 months after term (p < 0.05). CONCLUSION In preterm infants with severe chronic lung disease and brain lesions, dexamethasone treatment leads to an acute reduction in motility and changes in the speed and amplitude of GMs. Until more is known about long-term neurologic sequelae, a cautious use of systemic dexamethasone therapy in preterm infants is recommended.

Quality of general movements in preterm infants with transient periventricular echodensities

By means of sequential videotape recordings, the relevance of the quality of general movements for neurological outcome was determined in a group of 21 appropriate‐for‐gestational‐age preterm infants with transient periventricular echodensities of variable localization and duration and in 6 infants without echodensities. Echodensities, especially in the parieto‐occipital area, affected the quality of general movements. Echodensities persisting beyond 14 d were associated with abnormal general movements; infants with echodensities up to 14 d had either normal or abnormal general movements. The developmental course of movement quality was correlated to neurological outcome (p < 0:005): normal outcomes were found in 11/12 infants with normal general movements throughout and in 9/11 infants with transient abnormal general movements; all 4 infants with persistent abnormal general movements had impaired outcomes. In infants with transient echodensities, longitudinal assessment of the quality of general movements helps to determine if there is brain dysfunction, either transient or persistent, and identifies infants at risk for impaired neurological outcomes.

Cerebral Oxygenation in Preterm Infants With Germinal Matrix-Intraventricular Hemorrhages

Background and Purpose— Preterm infants are at risk of developing germinal matrix hemorrhages–intraventricular hemorrhages (GMH-IVH). Disturbances in cerebral perfusion are associated with GMH-IVH. Regional cerebral tissue oxygen saturation (rcSO2), measured with near-infrared spectroscopy, and fractional tissue oxygen extraction (FTOE) were calculated to obtain an indication of cerebral perfusion. Our objective was to determine whether rcSO2 and FTOE were associated with GMH-IVH in preterm infants. Methods— This case–control study included 17 preterm infants with Grade I to III GMH-IVH or periventricular hemorrhagic infarction (median gestational age, 29.4 weeks; range, 25.4 to 31.9 weeks; birth weight, 1260 g; range, 850 to 1840 g). Seventeen preterm infants without GMH-IVH, matched for gestational age and birth weight, served as control subjects (gestational age, 29.9 weeks; range, 26.0 to 31.6 weeks; birth weight, 1310 g; range, 730 to 1975 g). RcSO2 and transcutaneous arterial oxygen saturation were measured during 2 hours on Days 1 to 5, 8, and 15 after birth. FTOE was calculated as FTOE=(transcutaneous arterial oxygen saturation−rcSO2)/transcutaneous arterial oxygen saturation. Results— Multilevel analyses showed that rcSO2 was lower and FTOE higher in infants with GMH-IVH on Days 1, 2, 3, 4, 5, 8, and 15. The largest difference occurred on Day 5 with rcSO2 median 64% in infants with GMH-IVH versus 77% in control subjects and FTOE median 0.30 versus 0.17. RcSO2 and FTOE were not affected by the grade of GMH-IVH. Conclusions— Preterm infants with GMH-IVH had lower rcSO2 and higher FTOE during the first 2 weeks after birth irrespective of the grade of GMH-IVH. This suggests that cerebral perfusion is decreased persistently for 2 weeks in infants with GMH-IVH, even in the presence of mild hemorrhages.

Cerebral oxygen saturation and extraction in preterm infants with transient periventricular echodensities.

OBJECTIVE: Our aim was to determine regional cerebral tissue oxygen saturation and fractional tissue oxygen extraction in preterm infants with transient periventricular echodensities. We hypothesized that as a result of reduced cerebral perfusion, regional cerebral tissue oxygen saturation will be lower and fractional tissue oxygen extraction will be higher during the first days after birth. PATIENTS AND METHODS: This was a prospective, observational study of 49 preterm infants (gestational age median: 30.1 weeks [26.0–31.8 weeks]; birth weight median: 1220 g [615–2250 g]). We defined transient periventricular echodensities as echodensities that persisted for >7 days. Regional cerebral tissue oxygen saturation was measured on days 1–5, 8, and 15 after birth. Fractional tissue oxygen extraction was calculated as (transcutaneous arterial oxygen saturation − regional cerebral tissue oxygen saturation)/transcutaneous arterial oxygen saturation. RESULTS: Transient periventricular echodensities were found in 25 of 49 infants. During the first week we found no difference between the 2 groups for cerebral tissue oxygen saturation and fractional tissue oxygen extraction values. On day 15 after birth, cerebral tissue oxygen saturation was lower in preterm infants with transient periventricular echodensities (66%) compared with infants without echodensities (76%) (P = .003). Fractional tissue oxygen extraction in infants with transient periventricular echodensities (0.30) was higher than fractional tissue oxygen extraction in infants without transient periventricular echodensities (0.20) (P < .001). The differences could not be explained by confounding variables. CONCLUSIONS: Persistent transient periventricular echodensities may be associated with increased cerebral oxygen demand after the first week after birth, which is contrary to our hypothesis. Cerebral oxygenation may be involved in the recovery of perinatal white matter damage.

Functional outcome at school age of neonatal post-hemorrhagic ventricular dilatation

BACKGROUND Specific knowledge about the functional outcome of preterm born children with post-hemorrhagic ventricular dilatation (PHVD) is lacking. OBJECTIVES To determine functional outcome at school age in children with post-hemorrhagic ventricular dilatation and to identify whether PHVD characteristics increased the risk for deficits. METHODS Single-center case-control study. Included were preterm children born between 1996 and 2003 who had PHVD in their neonatal period. The controls were children matched for gestation, gender, and year of birth. At school age, using standardized tests and questionnaires, we assessed intelligence, attention, verbal memory, executive functioning, visual perception, visuomotor integration, motor skills, and behavior. RESULTS Of 34 children with PHVD 28 survived, three of whom could not be tested at school age (one childs parents declined and two were lost to follow-up). At a mean age of 10years (6-14years) the total and verbal IQs of the remaining 25 children (17 boys, 8 girls) were significantly lower compared to controls (difference in total IQ-14 points, verbal IQ-9 points, P=0.001and P=0.009, respectively). After adjustment for possible confounders, the performance of the PHVD group was poorer on visual perception and attention tests. Selective attention showed a trend toward risk of borderline and abnormal scores (OR 4.03, 95%-CI 0.84-19.2). Within the PHVD group, total IQ was significantly lower (P=0.048) in those who had undergone surgical intervention (n=12). CONCLUSION At school age, intelligence, attention, and visual perception were more affected in the PHVD group than in the matched controls. Surgical intervention was associated with lower IQ scores.

Clinical Importance of a Fixed Bowel Loop in the Treatment of Necrotizing Enterocolitis

Background: The need for surgical treatment in neonates with necrotizing enterocolitis (NEC) is associated with high mortality. Although pneumoperitoneum and progressive disease are generally accepted indications for surgery, it is unclear whether a fixed bowel loop (FBL) should prompt surgery. Objective: To determine the relationship between an FBL, type of treatment, and death in the management of NEC. Methods: Retrospective analysis (January 2000-December 2011) of all neonates with definite NEC in a tertiary neonatal intensive care unit. FBL was defined as a persistent (i.e. >24 h) dilated intestinal segment present on serial abdominal X-rays. Results: NEC was diagnosed in 141 neonates (median gestational age 30 weeks; median birth weight 1,340 g). An FBL was reported in 38 (27%) patients, of whom 18 were treated surgically. Mortality among FBL patients was independent of the type of treatment (surgical versus conservative): 8/18 and 7/20, respectively (p = 0.55). Of the 103 patients without FBL, 37 (36%) were treated surgically, which is comparable to the FBL group. Again, mortality was not related to the type of treatment (surgical versus conservative): 5/37 and 6/66, respectively (p = 0.49). The presence of an FBL was associated with mortality: more patients with an FBL (15/38, 39%) died than without an FBL (11/103, 11%; odds ratio 5.45, 95% confidence interval 2.21-13.45; p < 0.01). Conclusions: In NEC patients, an FBL is associated with increased mortality. On its own it has moderate significance to guide treatment. Nevertheless, because it reflects disease severity, early recognition is important and prompt (surgical) treatment should be considered.