Breda C. Hayes

Behavioural and emotional outcome of very low birth weight infants – literature review

Objective. To examine whether low birth weight (LBW) children are at greater risk for behavioural and emotional problems than normal birth weight children. Methods. Electronic databases (PubMed, Google) were searched. Key search terms (LBW, emotional behavioural outcome) were used to identify possible studies. Selection of studies was limited to those including detailed assessment of behavioural and/or emotional outcome of very low birth weight or very preterm infants with normal term infants as controls, published from the year 2000 to date. A total of 20 studies were identified for inclusion in our review. Results. Overall studies showed a significant increase in behavioural problems in particular poor attention span, withdrawn behaviour and poorer adaptive functioning. Rates of a clinically significant neurobehavioural impairment in cases ranged from 25% to 55% with controls displaying a relatively constant rate of around 7%. Attention problems without hyperactivity (ADD) were more common than ‘classical attention deficit/hyperactivity disorder’ in LBW children. Only 4% of the LBW children had previously been referred to a consultant psychiatric suggesting that at present these problems are being under-recognised. Conclusion. VLBW or very preterm infants are at significant risk of behavioural and emotional problems. The risk is further increased when cognitive or motor difficulties are present or when social circumstances are poor.

The placenta in infants >36 weeks gestation with neonatal encephalopathy: a case control study

Objective To determine placental characteristics associated with neonatal encephalopathy (NE) and correlate these with short- and long-term neurodevelopmental outcome. Design Case/control study. Setting Neonatal Intensive Care Unit, Rotunda Hospital, Dublin, Ireland. Patients Newborns ≥36 weeks gestation, with NE (cases). Healthy term newborns (controls). Interventions Placental pathology was obtained from the official placental report. Brain MRI was blindly reviewed. Children were assessed using a variety of standardised assessments. Data were analysed using multinomial logistic regression analysis. Main outcome measures RRR for grade of encephalopathy. OR for neurodevelopmental outcome. Results Placental reports were available on 141 cases (76 grade 1; 46 grade 2; 19 grade 3) and 309 control infants. Meconium phagocytosis, haemorrhage, raised placental to birth weight ratio and/or markers of infection/inflammation were independently associated with NE and showed a synergistic effect, when combined, for short- and long-term impairments. Conclusions Evaluation of the mechanisms leading to the placental characteristics identified may help to characterise the causal pathway of NE.

Cerebral palsy after maternal trauma in pregnancy

Ten children (six males, four females) with spastic (n=9) and mixed spastic‐dyskinetic (n=1) cerebral palsy were born at term to mothers who earlier in the pregnancy had been involved in accidents without suffering overt abdominal injury, placental abruption, or premature onset of labour. At follow‐up (at ages 2‐24y), Gross Motor Function Classification System levels were II (n=7) and V (n=3). Cognitive level was normal in five patients, while learning disability was mild to moderate in two and severe in three. Magnetic resonance imaging of the brain in all children, assessed blind to the dates of maternal trauma in pregnancy, showed lesions consistent with prenatal vascular insult at the time of the trauma. Feasible mechanisms of brain injury include reduced placental blood flow and/or placental embolization.

A case-control study of hypoxic-ischemic encephalopathy in newborn infants at >36 weeks gestation.

OBJECTIVE The purpose of this study was to determine risk factors that are associated with hypoxic ischemic encephalopathy (HIE). STUDY DESIGN This was a case-control study that included newborn infants with HIE who were admitted to the hospital between January 2001 and December 2008. Two control newborn infants were chosen for each case. Logistic regression and classification and regression tree (CART) analysis that compared control infants and cases with grade 1 HIE and control infants and cases with grades 2 and 3 HIE was performed. RESULTS Two hundred thirty-seven cases (newborn infants with grade 1 encephalopathy, 155; newborn infants with grade 2 encephalopathy, 61; newborn infants with grade 3 encephalopathy, 21) and 489 control infants were included. Variables that were associated independently with HIE included higher grade meconium, growth restriction, large head circumference, oligohydramnios, male sex, fetal bradycardia, maternal pyrexia and increased uterine contractility. CART analysis ranked high-grade meconium, oligohydramnios, and the presence of obstetric complications as the most discriminating variables and defined distinct risk groups with HIE rates that ranged from 0-86%. CONCLUSION CART analysis provides information to help identify the time at which intervention in labor may be of benefit.

Brain magnetic resonance imaging and outcome after hypoxic ischaemic encephalopathy

Abstract Objective: To correlate pattern of injury on neonatal brain magnetic resonance imaging (MRI) with outcome in infants ≥36 + 0 weeks gestation with hypoxic ischaemic encephalopathy. Methods: Prospective cohort study. Images were blindly reviewed. Children were assessed using a variety of standardised assessments. Results: MRI brain was performed on 88 infants. Follow up was available in 73(83%) infants. Eight of 25(32%) children with normal imaging had below normal assessment scores. Eight infants (12%) had isolated punctate white matter lesions and five of these had abnormal assessment scores. Death and cerebral palsy were seen only in children with imaging scores ≥3 on basal ganglia/thalami (BGT) score or ≥4 on watershed score. No developmental concerns were raised in 3/7(43%) infants with isolated watershed injury. Ten of 13(77%) infants with isolated BGT injury died or developed cerebral palsy. All 23 children with posterior limb of the internal capsule (PLIC) injury displayed developmental difficulties. Conclusions: Almost one-third of infants with a normal MRI brain may be at risk of developmental problems. Punctate foci of white matter injury are common and not always benign. PLIC involvement is usually associated with neurological sequelae including isolated cognitive deficits. Worst outcomes are associated with basal ganglia injury.

Timing of administration of antenatal magnesium sulfate and umbilical cord blood magnesium levels in preterm babies

Abstract Background: The optimum timing of administration of magnesium sulfate (MgSO4) in relation to delivery is not known. The general consensus is to achieve administration to the mother at least 4 hours prior to preterm delivery. Objective: To investigate potential predictors of umbilical cord blood magnesium (Mg) concentrations, in particular, timing of antenatal MgSO4 administration in relation to delivery. Study design: A prospective observational study of infants delivered at less than 32 weeks’ gestational age. Cord bloods samples were collected at delivery and Mg levels analyzed. Results: Of the 81 included cases, five received no antenatal MgSO4, 65 received a 4 g bolus only, and 11 received a 4 g bolus and 1 g/hour infusion. The median time of bolus administration before delivery was 104 minutes (IQR: 57–215). The mean magnesium level was 0.934 mmol/L in the no antenatal MgSO4 group, 1.018 mmol/L in the bolus only group, and 1.225 mmol/L in the bolus and infusion group (p < .05). In the bolus only group, the highest mean magnesium concentration (1.091 mmol/L) was achieved with administration 1–2 hours before delivery, but the difference was small and not statistically significant. On multiple regression analysis, lower birthweight Z scores and gestational age were independently associated with higher cord blood Mg levels. Conclusions: In the bolus only group, the highest mean Mg levels were observed with administration 1–2 hours before delivery, but the findings were not statistically significant. Compared to the rest of the cohort, higher Mg levels were found when a bolus was followed by an infusion. Following a MgSO4 bolus, some growth restricted extremely preterm babies may have higher Mg levels than would be otherwise expected.

Head size and growth in the very preterm infant: a literature review

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