Barry E. Fleisher

Movement, imaging and neurobehavioral assessment as predictors of cerebral palsy in preterm infants.

Objective:To study the relative efficacy of three early predictors of cerebral palsy.Method:One Hundred and thirty infants with birth weight <1500 g were recruited. Video recordings of spontaneous general movements were made at 36 and 52 weeks postconceptional age. Magnetic resonance imaging and the neurobehavioral assessment of the preterm infant were done at 36 weeks postconceptional age. Follow-up neurological examination and Bayley assessments were made at 18 months corrected age to make early identification of cerebral palsy.Results:Magnetic resonance imaging gave the best specificity and accuracy of 91 and 84% respectively. General movements at 52 weeks showed an improved specificity and accuracy over performance at 36 weeks postconceptional age. The negative predictive value for all methods tested was between 90 and 97%. Combining the results of magnetic resonance imaging and the neurobehavioral assessment improved the sensitivity of prediction to 80%, suggesting that a holistic approach to early detection of cerebral lesions is preferable to a single test.Conclusions:The majority of infants who appeared to behave within normal limits and exhibit normal brain structure in the newborn period were classified as neurologically intact at follow-up.

The need for long-term audiologic follow-up of neonatal intensive care unit (NICU) graduates

OBJECTIVE To evaluate the adequacy of newborn hearing screening in the identification of hearing loss in post-neonatal intensive care unit (NICU) infants. METHODS Eighty-two post-NICU infants who had initially passed automated auditory brainstem response (AABR) screening were studied prospectively between November 1997 and July 1999. Tympanometry and transient evoked otoacoustic emissions (TEOAE) were used to evaluate middle ear status and screen the hearing of subjects when they were seen routinely in the Mary L. Johnson Infant Development Clinic, where NICU graduates are followed at our institution. TEOAEs were not performed in subjects with abnormal tympanometry, defined as negative pressures greater than 200 daPa or flat tympanograms. RESULTS Of the 82 subjects, 31 (37%) had abnormal tympanometry in at least one ear, with 24 (29%) exhibiting abnormal values bilaterally. Two subjects were identified with delayed-onset or previously undiagnosed sensorineural hearing loss. One had a history of persistent pulmonary hypertension (PPHN) and extracorporeal membrane oxygenation. The other infant had no risk factors for sensorineural hearing loss. CONCLUSIONS Our data indicate that newborn hearing screening programs may not provide adequate vigilance for NICU graduates. The high incidence of abnormal middle ear status and the identification of delayed-onset hearing loss in an infant without known risk factors highlights the need for close audiologic and speech/language follow-up in the post-NICU population.

Neurobehavioral assessment predicts differential outcome between VLBW and ELBW preterm infants

OBJECTIVE:To evaluate the impact of birth weight on development of very low birth weight (VLBW) infants using the Neurobehavioral Assessment of the Preterm Infant (NAPI) before hospital discharge, and to show the relation to follow-up outcomes at 12, 18 and 30 months of age.STUDY DESIGN:In total, 113 preterm infants were assessed with the NAPI at 36 weeks postmenstrual age. Later, neurodevelopment was examined using the Bayley Infant Neurodevelopmental Screener (BINS) at 12 months and the Bayley Scales of Infant Development, at 18 and 30 months. The cohort was divided into two groups, based on birth weight, extremely low birth weight (ELBW) (<1000 g) and VLBW (1000 to 1500 g).RESULTS:ELBW infants showed significantly lower NAPI scores compared with VLBW infants at 36 weeks. The predischarge NAPI scores correlated with the 12, 18 and 30 months scores when the ELBW infants continue to have lower performance than the VLBW infants. In all, 14 infants developed cerebral palsy. These infants had significantly lower NAPI, BINS and Bayley scores compared with all other preterm infants.CONCLUSION:NAPI before discharge provides clinically meaningful information related to later neurodevelopmental outcome.

Neonatal Severity of Illness Scorinng Systems: A Comparison

Several different scoring systems have been developed to predict neonatal morbidity and mortality. In this investigation we compared the utility of four severity of illness scoring systems (SISS) as predictors of days on ventilator (DOV), length of hospital stay (LOS), and mortality in very-low-birth weight (VLBW) premature infants who required mechanical ventilation. The SISS assessed were the Score for Neonatal Acute Physiology (SNAP); the Score for Neonatal Acute Physiology—Perinatal Extension (SNAP+PE); Clinical Risk Index for Babies (CRIB), and the Sinkin Score at 12 hours (SS12). Results revealed significant correlations among the SS12, SNAP, SNAP+PE, CRIB, birth weight (BW), DOV, and LOS. However, none of the systems we assessed offered striking advantage over BW in a VLBW ventilated group.

Effects of Skin-to-Skin Holding on General Movements of Preterm Infants

The study objective was to test the hypothesis that the effect of skin-to-skin (STS) holding increases the ratio of rest to activity in low birth weight preterm infants. Ten infants with birthweight <2,000 grams were videotaped before and after STS holding. Video recordings were analyzed to determine the number of general movements. We found no statistically significant difference between the percentage of general movements over the two periods. We conclude that the ratio of rest-activity before and after STS holding does not change as measured by occurrence of general movements.

Intracranial abnormalities and neurodevelopmental status after venovenous extracorporeal membrane oxygenation

Computed tomography scans of the head and early neurodevelopmental assessment (Bayley Scales of Infant development) were recorded for 24 surviving infants who received venovenous extracorporeal membrane oxygenation and were compared with those of infants treated with venoarterial bypass matched by diagnosis and oxygenation index before extracorporeal membrane oxygenation. A comparable neuroradiographic and early neurodevelopmental outcome was documented for survivors of venoarterial and venovenous extracorporeal membrane oxygenation.

Comparison between Neuroimaging and Neurobehavioral Assessments of the Very Low Birthweight Preterm Infant

Comparison between Neuroimaging and Neurobehavioral Assessments of the Very Low Birthweight Preterm Infant

INDIVIDUALIZED DEVELOPMENTAL CARE FOR VERY LOW BIRTH WEIGHT (VLBW) PREMATURE INFANTS: IMPROVED |[ldquo]|STATE SYSTEM CONTROL|[rdquo]| WITHOUT ADVANCED DEVELOPMENT IN SLEEP MEASURES USING THE MOTILITY MONITORING SYSTEM (MMS).

Objective: We hypothesized that individualized developmental care for the VLBW Neonatal Intensive Care Unit (NICU) infant would result in advanced sleep development (measured by the MMS). Population: We conducted sleep studies using the MMS on 28 preterm infants who were part of a larger group enrolled in the Neonatal Individualized Developmental Care and Assessment Program (NIDCAP) at Stanford. Enrollment criteria for this program included birth wt. ≤1250g and mechanical ventilation for more than 24h during the first 48h of life. Infants were randomly assigned to Intervention(INT, n=14) or Control (C, n=14) groups. Groups were similar for severity of illness. Researchers recording and scoring the sleep data were blinded. Care plans were devised and implemented for the INT infants, as described (Als et al. JAMA. 1994). C infants received routine NICU nursing care. Both INT and C infants were evaluated at 42 weeks post-conceptional age (PCA) by a blinded examiner using the Assessment of Premature Infant Behavior (APIB) tool. The APIB assesses an infants behavior in five areas or systems including“state system control” (evaluation of sleep and wake states for maturity). Methods: MMS technique used a pressure sensitive pad, amplifier, and recorder. Studies were conducted for 48 continuous hours at 36 wks PCA and at 3 mos corrected age (CA). Data were scored for states, state transitions, and out of crib time. Results: INT infants showed better sleep and wake “state system control” than C infants as measured by the APIB (p=.03). However, there was no significant difference between the two groups at either age on any MMS sleep measure. There were significant maturation effects in both groups between 36 wks PCA and 3 mos CA(% Quiet Sleep/Total Sleep Time increase: INT=11, C=6 and% Active Sleep/Total Sleep Time decrease: INT=11, C=6 all ps <0.006). Conclusion: Improved medical outcome measured by shorter time on mechanical ventilation, fewer days to full enteral feeds and decrease in length of hospitalization reported in infants who have had developmental care implemented does not appear to be associated with improvement in sleep development or in the amount of sleep. Improvement in “state system control” occurs without neurodevelopmental maturation in sleep as measured by the MMS.