Edmond Kelly

Neurodevelopmental Outcomes After Open Heart Operations Before 3 Months of Age

BACKGROUNDnThe purpose of this study was to monitor developmental progress and identify predictors of developmental outcomes at 2 years after operation in infants who underwent a surgical procedure with cardiopulmonary bypass (CPB) at less than 3 months of age.nnnMETHODSnPatients (N=131 enrolled; N=106 assessed) less than 3 months of age at the time of cardiac operation were prospectively enrolled (years 1999-2003) and assessed at 8, 12, and 24 months after operation. Patients with preexisting conditions independently associated with poor neurodevelopmental outcomes were excluded. Fine and gross motor development was formally assessed at all 3 visits, and parent ratings of development across several domains were obtained. Neurodevelopment was formally assessed at 24 months of age using the Bayley Scales of Infant Development, 2nd edition (BSID-II) Mental Development Index score (MDI).nnnRESULTSnSignificant gross motor difficulties were identified at 8 months of age (p<0.001) and, although improved by the 24-month assessment, remained lower than average. Fine motor skills showed a significant decrease from 8 to 24 months of age (p=0.001). Factors associated with poorer neurodevelopmental outcome (BSID-II MDI) at 24 months after operation included a diagnosis of univentricular anatomy or complex coarctation of the aorta, higher complexity of the surgical procedure, longer duration of hospital stay, and presence of complications in the postoperative period.nnnCONCLUSIONSnChildren undergoing repair of congenital heart disease (CHD) still have impaired development 2 years after the operation. Observed patterns of development were specific to the skill being assessed and related to both anatomic complexity and increased complexity of care received.

Neonatal survival rates in 860 singleton live births at 24 and 25 weeks gestational age. A Canadian multicentre study

Objective To determine the current survival rate of singleton living newborns born at gestational age of 24 and 25 weeks, using obstetric factors available to the physician before birth.

Fetal thoracoamniotic shunting for large macrocystic congenital cystic adenomatoid malformations of the lung

To evaluate fetal thoracoamniotic shunting for isolated large macrocystic congenital cystic adenomatoid malformations (CCAM) of the lung.

Haemodynamic changes after delivery room surfactant administration to very low birth weight infants

Introduction Surfactant replacement therapy (SRT) reduces respiratory morbidity and mortality in premature infants. The goal of this study was to characterise the effects of delivery room SRT on the ductus arteriosus and early neonatal haemodynamics. Methods A prospective observational study was conducted in preterm infants of less than 32 weeks gestation who received SRT within 30 min of birth. Serial echocardiography was performed before and after SRT. Characteristics of the ductus arteriosus, myocardial performance, right ventricular output (RVO) and left ventricular output (LVO) and the ratio of RVO:LVO were measured. Results Sixteen babies, born at 28.3±1.3 weeks gestation and weighing 1289±224 g, were studied. SRT was associated with an improvement in the arterial oxygen tension:fractional inspired oxygen ratio (p<0.001), increased systolic and decreased diastolic arterial pressure (p<0.05). The ductus arteriosus was patent in all and transductal flow was unrestrictive and exclusively left-to-right after SRT. An increase in transductal diameter (p<0.001), left atrium:aortic ratio (p=0.006) but a decrease in left ventricular end-diastolic dimension (p=0.02) was identified. Conclusion SRT administration was followed by increased RVO but decreased LVO, resulting in an increased RVO:LVO ratio and an increase in ductal size. Delivery room administration of SRT is associated with major haemodynamic changes. The impact of these changes needs prospective evaluation.

Functional and Antigenic Concentrations of Alpha-1-Proteinase Inhibitor after Administration for the Prevention of Chronic Lung Disease of Prematurity

Objective and Methods: Alpha-1-proteinase inhibitor (A1PI) supplementation has been used in adults with inherited alpha-1-antitrypsin (A1AT) deficiency to impede the development of emphysema. A1PI supplementation may also be useful for protecting premature neonates who receive mechanical ventilation from the development of chronic lung disease (CLD). However, the pharmacokinetics of exogenous A1PI in this population are unknown. We attempted to determine the disposition of A1PI in premature infants with birth weight 600–1,250 g who received 60 mg/kg on days 0, 4, 7 and 14 in a randomized, placebo-controlled, double-blind trial. Functional and antigenic plasma concentrations of A1PI were measured at specified time points. Results: On both functional and antigenic assays, concentrations began in the normal adult range and rose from day 0 to 10 then fell slightly, but remained above initial values. The concentrations were not significantly different between the treatment and placebo groups. Conclusions: The results of this study indicate that neonatal pharmacokinetics of A1PI differ markedly from those of the adult. Total plasma clearance of exogenous A1PI seems high in the ventilated premature neonate. Higher or more frequent doses may be necessary to maintain A1PI plasma concentrations above baseline.

Neurodevelopmental Outcomes of Infants Born at <29 Weeks of Gestation Admitted to Canadian Neonatal Intensive Care Units Based on Location of Birth

Objective To compare mortality and neurodevelopmental outcomes of outborn and inborn preterm infants born at <29 weeks of gestation admitted to Canadian neonatal intensive care units (NICUs). Study design Data were obtained from the Canadian Neonatal Network and Canadian Neonatal Follow‐up Network databases for infants born at <29 weeks of gestation admitted to NICUs from April 2009 to September 2011. Rates of death, severe neurodevelopmental impairment (NDI), and overall NDI were compared between outborn and inborn infants at 18‐21 months of age, corrected for prematurity. Results Of 2951 eligible infants, 473 (16%) were outborn. Mean birth weight (940 ± 278 g vs 897 + 237 g), rates of treatment with antenatal steroids (53.9% vs 92.9%), birth weight small for gestational age (5.3% vs 9.4%), and maternal college education (43.7% vs 53.9%) differed between outborn and inborn infants, respectively (all P values <.01). The median Score for Neonatal Acute Physiology‐II (P = .01) and Apgar score at 5 minutes (P < .01) were higher in inborn infants. Severe brain injury was more common among outborn infants (25.3% vs 14.7%, P < .01). Outborn infants had higher odds of death or severe NDI (aOR 1.7, 95% CI 1.3‐2.2), death or overall NDI (aOR 1.6, 95% CI 1.2‐2.2), death (aOR 2.1, 95% CI 1.5‐3.0), and cerebral palsy (aOR 1.9, 95% CI 1.1‐3.3). Conclusions The composite outcomes of death or neurodevelopmental impairment were significantly higher in outborn compared with inborn infants admitted to Canadian NICUs. Adverse outcomes were mainly attributed to increased mortality and cerebral palsy in outborn neonates.

Severe Neurodevelopmental Impairment in Neonates Born Preterm: Impact of Varying Definitions in a Canadian Cohort

Objective To assess the impact of variations in the definition of severe neurodevelopmental impairment (NDI) on the incidence of severe NDI and the association with risk factors using the Canadian Neonatal Follow‐Up Network cohort. Study design Literature review of severe NDI definitions and application of these definitions were performed in this database cohort study. Infants born at 23‐28 completed weeks of gestation between 2009 and 2011 (n = 2187) admitted to a Canadian Neonatal Network neonatal intensive care unit and assessed at 21 months corrected age were included. The incidence of severe NDI, aORs, and 95% CIs were calculated to express the relationship between risk factors and severe NDI using the definitions with the highest and the lowest incidence rates of severe NDI. Results The incidence of severe NDI ranged from 3.5% to 14.9% (highest vs lowest rate ratio 4.29; 95% CI 3.37‐5.47). The associations between risk factors and severe NDI varied depending on the definition used. Maternal ethnicity, employment status, antenatal corticosteroid treatment, and gestational age were not associated consistently with severe NDI. Although maternal substance use, sex, score of neonatal acute physiology >20, late‐onset sepsis, bronchopulmonary dysplasia, and brain injury were consistently associated with severe NDI irrespective of definition, the strength of the associations varied. Conclusions The definition of severe NDI significantly influences the incidence and the associations between risk factors and severe NDI. A standardized definition would facilitate site comparisons and scientific communication.

OC84: How early do imaging changes occur in MC/DA surviving twins following co‐twin demise?

Results: Cerebral abnormalities developed prenatally in 27 fetuses (9.37%, 27/288). Prenatal diagnosis of these lesions was achieved primarily by US and MRI in 21/27 (78%) and in 6/27 (22%) fetuses respectively. Cerebral abnormalities developed following primary laser coagulation, serial amnioreduction or expectant management in 12/222 (5.40%), in 9/124 (13.63%) and in 3/14 (21.4%) fetuses respectively. Abnormalities developed after single intrauterine fetal death (IUD) in 14 cases including 6 severely anemic survivors as a result of exsanguination in their dead co-twin. These lesions developed following primary laser coagulation, amniodrainage and expectant management in 3/55 (5.45%), 7/20 (35%) and 1/14 (7%) cases respectively. Conclusions: Cerebral morbidity in TTTS mainly occurs following vascular disruptive lesions. Both donors and recipients are at risk of developing either ischemic or hemorrhagic lesions. The risk of developing cerebral lesions in single survivors is significantly less following laser treatment. Timing of the triggering event is critical for serial US and MRI follow-up examination.