Cara Coffman

Neurodevelopmental status at age five years of neonates treated with extracorporeal membrane oxygenation

OBJECTIVE To determine the neurodevelopmental status at age 5 years among children who received extracorporeal membrane oxygenation (ECMO) in the newborn period as a treatment for severe cardiorespiratory failure. METHODS We conducted a prospective cohort study of 103 five-year-old ECMO-treated children born between June 1984 and July 1988, and treated at our institution. Thirty-seven healthy control children were recruited locally. The assessment protocol included a complete neuropsychologic assessment, psychosocial assessment with parent questionnaires, a standard neurologic evaluation, assessment of gross motor and fine motor function, a medical history, and physical examination. RESULTS Major disability was present in 17 of the ECMO cohort. Eleven ECMO-treated children (11%) were mentally retarded, one of whom was profoundly impaired. Two additional children had severe learning disabilities. Cerebral palsy was diagnosed in 5 (5%) ECMO-treated children, but all cases were mild in nature and the patients were walking unaided. One child has paraplegia. The mean Full Scale, Verbal, and Performance IQs of the EMCO-treated children were within the normal range, but as a group were significantly lower than in control children (96 vs 115, p < 0.001). Children treated with ECMO had increased risk relative to the control children for academic difficulties at school age (49% VS 22%, P < 0.01) and a higher rate of behavioral problems reported by parents (42% vs 16%, p = 0.01). CONCLUSIONS The rate of major disability was comparable to that in other high-risk populations. The high rate of behavioral problems and increased risk of subsequent school failure among nonretarded ECMO-treated children supports the need for close follow-up of these children after hospital discharge.

Pattern of Neuropsychological Deficit at Age Five Years Following Neonatal Unilateral Brain Injury

The pattern of language deficit following left-hemisphere brain injury and visual/spatial deficit following right-hemisphere injury in an adult or older child is well recognized, but has been inconsistently reported following presumed neonatal brain injury. Our prospective study of 24 children at age 5 with documented neonatal unilateral brain injury lends support to the theory of hemisphere specialization at the time of birth. Twelve children who had unilateral left-hemisphere lesion were compared to 12 children with unilateral right-hemisphere lesion of similar timing and severity. Relative visual/spatial deficit following right-hemisphere lesion and receptive language deficit following left-hemisphere lesion were identified. Lateralized measures of grip strength, fine motor speed, and fine motor dexterity were not significantly different between the groups for either hand in this nonhemiparetic study sample. Only one child with a left-hemisphere lesion was left-handed, and only one child (right-lesion) had a hemiparesis.

Cardiopulmonary Outcome at Age 10-13yrs Following Neonatal Extracorporeal Membrane Oxygenation(ECMO)

Cardiopulmonary Outcome at Age 10-13yrs Following Neonatal Extracorporeal Membrane Oxygenation(ECMO)

Neurocognitive Status of HIV-infected Children at Age Three Years 264

This retrospective study delineates outcome status at age three by AIDS defining diagnosis for children with perinatally acquired HIV infection, and determines whether prenatal drug exposure and preterm birth are related to outcome status. The study sample consists of HIV-infected children who were attended by the Special Immunology Service and who had at least one developmental evaluation (Bayley or McCarthy Scales)during the study period(February 1991-May 1995). We selected a limited age range to determine neurocognitive outcome,(3 years +/- 6 months), distinguished outcome by AIDS defining illness (LIP and non-LIP, and incorporated mortality into a definition of extremely poor outcome status. We hypothesized that prenatal drug exposure and low birthweight would negatively impact outcome. Seventy-four children met the CDC criteria for diagnosis of HIV infection; 48 had AIDS (1987 AIDS surveillance case definition); 16 had LIP AIDS. All had receeived antiretroviral treatment. Twelve children were not available for testing within the age limit selected for study and were excluded. Twelve additional children died before they could be tested at age 3. The remaining 50 children all received neurocognitive testing at age 3 (+ 6 months). The majority were functioning within broadly normal limits on neurocognitive testing at age three (DQ >70). However, 53% of the children with a diagnosis of AIDS had neurocognitive test scores <70. Children who had LIP AIDS were less likely to score in that range than those with non-LIP AIDS, although more likely than HIV+ children who did not have AIDS (p=.009). Extremely poor outcome, as defined by the lower limit of the Bayley or McCarthy test (<50) or death by age three, occurred exclusively among those with a diagnosis of non-LIP AIDS. Lower birthweight was associated with extremely poor outcome status, although prenatal drug exposure was not. Outcome studies of HIV-infected children are a reflection of the survival of those less affected with the disease.

Neuropsychological outcome at age 5 following unilateral neonatal brain lesion. 1728

Retrospective studies of neonates who sustain unilateral brain lesions demonstrate small but persistent deficits contralateral to lesion side. Prospective studies have generally been constrained by small sample size, variability in age of lesion onset, and wide range of ages when outcome has been assessed. We report neuropsychological outcome at age five for 24 children who were ascertained in the neonatal period to have unilateral brain lesions (LL=12; RL=12). The sample is part of a cohort of 152 critically ill term neonates (> 2kg) who received routine neonatal neuroimaging (US/CT) following ECMO treatment for cardiorespiratory failure and were available for comprehensive neuropsychological evaluation at age 5. The lesion groups were comparable in terms of birthweight, GA, Apgar scores, neuroimaging severity score, ethnicity, maternal education, and age at test. One child (RL) had post-neonatal seizures. We compared performance on neuropsychological measures presumed subserved by the right hemisphere (e.g. visual/spatial, left-hand use) and left hemisphere (e.g. language, right-hand use). Data were converted to z-scores. The RL group showed a visual/spatial deficit relative to language, and the LL group showed the corresponding language deficit relative to visual/spatial skills. Verbal and visual memory scores were equivalent. One child in each group was left-hand dominant. Visual/motor tasks were poorer for the LL group, given the dominant hand was contralateral to the side of lesion. Overall, the effect was predictable for lesion side, although the effect size was small. Our data suggest residual effects at age five within the general pattern of recovery following lateralized neonatal brain injury. [Funded by NIH/NINDS]

NEUROPSYCHOLOGICAL OUTCOME AND EDUCATIONAL ADJUSTMENT TO FIRST GRADE OF ECMO-TREATED NEONATES. |[dagger]| 1684

One hundred and fifty-two 5 year-old ECMO survivors and 53 normal controls were given a comprehensive neuropsychological test battery and kindergarten screening. Mean Full Scale IQ (FSIQ) for the ECMO group was significantly lower than that of the Control group (94 ± 21 vs 108± 19, p<.001). Eighteen ECMO (12%) and 0 Controls had FSIQ < 70 (Mentally Retarded range). Academic Risk (as defined by FSIQ <80 or presence of neuropsychological deficits or failed kindergarten screen) was significantly higher among the ECMO children compared to Controls (50% vs 34%, p<.05). We obtained reports of school performance from parents of 101 of the 115 (88%) ECMO survivors when they should have completed first grade. Thirty-seven of the 101 (37%) children had experienced Academic Problems, as defined by either grade retention or having received special education resources. Seventy percent of the children with Academic Problems had been classified as Academic Risk on neuropsychological testing at age five. Eighty percent of the children classified at age five as No-Academic Risk were promoted to second grade without special education services. Stepwise regression analyses were computed with Academic Problems as the dependent variable. FSIQ,Academic Risk, and Neonatal Neuroimaging Score were entered as independent variables. Within the ECMO group (N=101), only FSIQ accounted for a significant proportion of the variance (43%). When only ECMO subjects with normal IQ were included in the analyses (N=91), only Academic Risk status accounted for a significant portion of the variance (29%). We conclude that neuropsychological testing for five year-old ECMO survivors can significantly enhance our ability to predict school difficulties. This study was funded by NIH/NINDS.

OUTCOME OF ECMO VS NEAR MISS ECMO PATIENTS AT FIVE YEARS OF AGE:† 1640

A total of one hundred and sixteen ECMO patients have been evaluated in our center at five years of age. Excluding the patients with primary diagnosis of congenital diaphragmatic hernia and sepsis, allowed us to compare 76 of five-year-old ECMO patients with 20, five-year-old Near Miss ECMO patients with similar primary diagnosis. Both groups were similar in gestational age, sex, Apgar scores and their primary diagnosis of pulmonary disease. Mean birth weight of ECMO patients (3.40 ± 0.60 Kg) was significantly higher than Near Miss group (3.02 ± 0.68 Kg) (p 40 was similar in both groups (22 ± 26 vs 26± 42), the Near Miss group spent longer time on PIP over 30 (75± 81 vs 42 ± 31), FiO2>0.70 (121 ± 81 vs 51± 34) and FiO2 of 1.00 (55 ± 71 vs 38 ± 23), and had longer duration of PCO2<30 (93 ± 64 vs 32 ± 35) respectively. Both groups had similar ethnic distribution and socioeconomic status as it was assessed by number of patients living in a single parent family, level of maternal education and home screening questionnaire. All 76 ECMO patients and 10 of the 20 Near Miss patients had neuroimaging studies. Total of 9 ECMO patients and 2 of the Near Miss patients that were studied had major neuroimaging abnormalities. Mean Full Scale IQ in ECMO patients was 96.88 ± 20.09 vs 91.50 ± 22.34 in Near Miss ECMO (p=.32). Academic screening for reading, writing, and arithmetic was similar in both groups with 46% of ECMO and 56% of Near Miss patients being at risk for school failure (p=.47). Parental reporting of psychosocial problems was similar for behavior adjustment and level of maternal stress, although parents of Near Miss patients reported an increased rate of child immaturity compared to ECMO patients (p=.005).