Charles R. Bauer

Long-term follow-up of extremely low birth weight infants with neonatal renal failure

The long-term outcome of 20 preterm infants with extremely low birth weight and acute renal failure in the neonatal period was studied retrospectively over an 18-year period. Those with progressive renal disease are compared with those with normal renal function. Current mean age is 7.5±4.6xa0years (range 3.2–18.5xa0years). Nine patients showed deterioration in renal function (low GFR group). Increasing proteinuria, as determined by random urine protein/creatinine ratio (Up/c), correlated with deterioration in renal function (r=0.8, P<0.0001). Prominent risk factors for progression were Up/c >0.6 at 1xa0year of age [100% sensitivity, 75% positive predictive value (PPV), P<0.01], serum creatinine >0.6xa0mg/dl at 1xa0year of age (75% sensitivity, 80% PPV, P<0.01), and a tendency to obesity with body mass index >85th percentile (89% sensitivity, PPV 67%, P=0.03). Loss of renal mass and nephrocalcinosis were not prognostic indicators. This report begins to identify important clinical parameters that should lead to closer surveillance and potential treatment interventions for preservation of renal function in a growing population of surviving low birth weight individuals.

Dexamethasone therapy increases infection in very low birth weight infants.

Background. Infection is a major complication of preterm infants, resulting in increased morbidity and mortality. We recently reported the results of a multicenter trial of dexamethasone initiated at 14 or 28 days in very low birth weight (VLBW) infants who were at risk for chronic lung disease; the results showed an increase in nosocomial bacteremia in the group receiving dexamethasone. This study is an in-depth analysis of bacteremia/sepsis and meningitis among infants enrolled in the trial. Methods. Data on cultures performed and antibiotic therapy were collected prospectively. Infections were classified as definite or possible/clinical. Results. A total of 371 infants were enrolled in the trial. There were no baseline differences in risk factors for infection. For the first 14 days of study, infants received either dexamethasone (group I, 182) or placebo (group II, 189). During this period, infants in group I were significantly more likely than those in group II to have a positive blood culture result (48% vs 30%) and definite bacteremia/sepsis/meningitis (22% vs 14%). Over the 6-week study period, 47% of those cultured had at least one positive blood culture result (53% in group I vs 41% in group II) and 25% of the infants had at least one episode of definite bacteremia/sepsis/meningitis (29% in group I vs 21% in group II). Among infants with definite infections, 46.8% were attributable to Gram-positive organisms, 26.6% to Gram-negative organisms and 26.6% to fungi. The factors present at randomization were evaluated for their association with infection. Group I assignment and H2blocker therapy (before study entry) were associated with increased risk of definite infection, whereas cesarean section delivery and increasing birth weight were associated with decreased risk. Conclusions. Infants who received a 14-day course of dexamethasone initiated at 2 weeks of age were more likely to develop a bloodstream or cerebrospinal fluid infection while on dexamethasone therapy than were those who received placebo. Physicians must consider this increased risk of infection when deciding whether to treat VLBW infants with dexamethasone.

Outcomes of very low birth weight twins cared for in the National Institute of Child Health and Human Development Neonatal Research Network’s intensive care units ☆ ☆☆ ★ ★★

OBJECTIVEnThe studys aim was to compare outcomes of very low birth weight twins with those of matched singletons.nnnSTUDY DESIGNnWith data from the Neonatal Research Network registry (May 1991 to December 1994), univariable and multivariable comparisons of very low birth weight twin pairs and singletons were performed in 2 subgroups: (1) all paired twins and singletons with birth weights between 401 and 1500 g and (2) all paired twins and singletons born at <28 weeks gestation.nnnRESULTSnTwins constituted 19% of infants admitted with very low birth weight. Mothers of twins were more likely to receive prenatal care, have labor, have cesarean delivery, and receive antenatal glucocorticoids. Twins were more likely to have respiratory disease and to receive surfactant. Second-born twins had more early respiratory disease but similar longer-term outcomes. The risks of death, chronic lung disease, and grade III or IV intracranial hemorrhage were similar in twins and singletons.nnnCONCLUSIONSnAlthough very low birth weight twins compose a sizable proportion of admissions, in National Institute of Child Health and Human Development Neonatal Research Network intensive care units, twins and singletons have similar outcomes.

Inaccuracy of Ballard scores before 28 weeks’ gestation

OBJECTIVEnBallard scores are commonly used to estimate gestational age (GA). The purpose of this study was to determine the accuracy of the New Ballard Score (NBS) for infants <28 weeks GA by accurate menstrual history and to evaluate NBS as an outcome predictor.nnnMETHODSnInfants weighing 401 to 1500 g in 12 National Institute of Child Health and Human Development Neonatal Research Network centers had NBS performed before age 48 hours. Accuracy of NBS estimates of GA was assessed for infants with GA determined by accurate menstrual history. In a larger cohort of infants, NBS was included in regression models of the association of NBS and death, poor outcome, and duration of hospital stay.nnnRESULTSnAt each week from 22 to 28 weeks GA by accurate menstrual history, NBS estimates exceeded GA by dates by 1.3 to 3.3 weeks, and estimates varied widely (range of widths of 95% CIs for the observations, 6.8 to 11.9 weeks). NBS did not contribute significantly to regression models of death, poor outcome, or duration of hospital stay.nnnCONCLUSIONSnInaccuracies in GA determined by the NBS should be considered when treating extremely premature infants, particularly in decisions to forego or administer intensive care. Refinement of GA scoring systems is needed to optimize clinical benefit.

Neurobehavioral Assessment Predicts Motor Outcome in Preterm Infants

OBJECTIVEnTo determine whether Neonatal Intensive Care Unit Network Neurobehavior Scales (NNNS) at 44 weeks predict motor outcome at 2 years in preterm infants from the Maternal Lifestyles Study (MLS).nnnSTUDY DESIGNnData were collected on all preterm infants (<36 weeks) in the MLS who underwent an NNNS at 44 weeks (n = 395) and neurologic examination at 12 to 36 months or Bayley Psychomotor Development Index (PDI) at 24 months (n = 270). Logistic regression analyzed NNNS summary scores associated with cerebral palsy (CP) or PDI <70, while controlling for birth weight </=1250 g.nnnRESULTSnEighteen of 395 infants (5%) had CP; 24 of 270 infants (9%) had PDI <70. CP was associated with low quality of movement (odds ratio [OR], 1.95; 95% CI, 1.24-3.06; P = .004) and high lethargy (OR, 1.67; 95% CI, 1.01-2.76; P = .045). The model contributed 19% of the variance in CP diagnosis at 12 to 36 months (R(2) = .19, P < .001). Low PDI was associated with low handling (OR, 1.83; 95% CI, 1.12-2.99; P = .017), low quality of movement (OR, 2.16; 95% CI, 1.38-3.38; P = .001), and hypotonia (OR, 1.63; 95% CI, 1.14-2.32; P = .007). The model contributed 26% of the variance in PDI <70 at 24 months (R(2) = 0.26, P < .001).nnnCONCLUSIONSnThe neurobehavioral profile of under-arousal in 44-week-old preterm infants may predict poor motor outcome.

Association between ruptured membranes tocolytic therapy, and respiratory distress syndrome

Two hundred ninety-seven patients from the placebo group of the National Institutes of Health Collaborative Study on Antenatal Steroid Therapy for prevention of respiratory distress syndrome were selected for analysis to investigate a possible association between premature rupture of the membranes, tocolytic therapy, and respiratory distress syndrome. Both premature rupture of the membranes and tocolytic therapy with isoxsuprine were individually associated with a lowered incidence of respiratory distress syndrome. However, when present together, their protective effect was not additive and resulted in a higher incidence of respiratory distress syndrome. It is suggested that the use of tocolytic therapy with beta-adrenergic agents be restricted to patients with intact membranes.