Francesco Cota

Cognitive Outcome at Early School Age in Term-Born Children With Perinatally Acquired Middle Cerebral Artery Territory Infarction

Background and Purpose— To assess cognitive outcome at early school age in term-born children with middle cerebral arterial (MCA) territory infarction of perinatal onset and examine the correlation between cognitive abilities and the extent of lesions as seen on neonatal MRI, epilepsy, and hemiplegia. Methods— Thirty-one children were seen as newborns with an acutely evolving MCA territory infarction documented on neonatal MRI scan. IQ was assessed (WIPPSI/WISC where appropriate) and they had a standardized neurological examination at early school age. Lesion(s) site was recorded from the neonatal images. Results— Twenty-eight of 31 children were assessed (median age 5.75 range 5.33 to 10.33 years); 1 child died and 2 were abroad. IQ was within the normal range (mean 104, range 82 to 144) in 21 (78%); 1 child did not complete all tests but had a normal PIQ; 3 had a low and 3 an exceptionally low IQ. Verbal IQs were more varied and lower than performance IQs especially in children from multilingual backgrounds. There was no consistent association between cognitive impairment, side, or extent of the MCA lesion. Cognitive impairments were more frequent in children with seizures or hemiplegia. All 6 children with low IQ also had behavioral problems or unusual associated clinical or scan features. Conclusions— In our cohort a low IQ at early school age did not occur in children with the common presentation of neonatal unilateral MCA territory infarction. Cognitive impairment appeared more frequently when an MCA arterial territory infarction, even if relatively small, was associated with other risk factors.

Effects of high versus standard early protein intake on growth of extremely low birth weight infants.

Objectives: Early provision of protein has been shown to limit catabolism and could improve growth. Our objective was to determine whether early aggressive protein intake improved growth outcomes of extremely low birth weight (ELBW) infants. Patients and Methods: ELBW infants were included in the study if they had no major congenital anomalies or renal failure and were still hospitalized at 36 weeks postmenstrual age. In 25 infants (HP) the early protein intake was planned to be 20% greater than in 31 historical controls (SP). Results: The 2 groups were similar in the baseline characteristics. The mean protein intake during the first 14 days of life was significantly greater in the HP group (3.1 ± 0.2 vs 2.5 ± 0.2 g/kg/d; P<0.0001). HP group showed lower postnatal weight loss (−3.1%; 95% confidence interval [CI] −5.9, −0.2) and earlier regain of birth weight (−4.1 days; 95% CI −6.6, −1.7). Mean blood urea nitrogen and bicarbonate levels were similar; mean serum glucose level was lower in the HP group (−21,7 mg/dL; 95% CI −41.9,−1.5). HP infants had a reduced fall in weight z score (−0.57; 95% CI −1.01, −0.12) and in length z score (−0.51; 95% CI −0.97, −0.05) from birth to discharge. Conclusion: Early high protein intake was associated with improved weight and length growth outcomes at discharge. These findings highlight the benefits of aggressive protein intake immediately after birth.

Preterm Small for Gestational Age Infants Are Not at Higher Risk for Parenteral Nutrition–Associated Cholestasis

OBJECTIVE To assess if being small for gestational age impacts parenteral nutrition-associated cholestasis (PNAC) development. STUDY DESIGN We reviewed all the very low-birth weight infants exposed to parenteral nutrition for >14 days from 1996 to 2006, comparing auxological and clinical data, as well as nutritional history, during the first 4 weeks of life of infants with cholestasis and control subjects. RESULTS Of 445 very low-birth weight infants, 55 had development of PNAC. Infants with cholestasis had lower birth weight and gestational age but similar birth weight z-score compared with infants without cholestasis, and they received a lower amount of enteral feeds (25.8 +/- 20.7 vs 67.9 +/- 33.0 mL/kg, P < .001), a greater amount of intravenous glucose (10.6 +/- 1.3 vs 7.5 +/- 2.5 g/kg, P < .0001), lipids (1.8 +/- 0.4 vs 1.3 +/- 0.5, P < .0001) and proteins (2.7 +/- 0.5 vs 1.9 +/- 0.7, P < .0001), and needed a higher number of days of fasting (13.2 +/- 6.7 vs 6.5 +/- 4.8, P < .001). Enteral intake between 0 and 21 days of life (OR 0.66; 95% CI 0.53, 0.81, P < .0001) and oxygen therapy (OR 1.05; 95% CI 1.01, 1.09; P = .030) were identified as the best independent predictors of PNAC. CONCLUSIONS Enteral feeding remains the main factor for the prevention of PNAC, whereas small for gestational age infants do not have a higher risk of PNAC.

A prospective, randomized, double blind study comparing lutein to placebo for reducing occurrence and severity of retinopathy of prematurity

Lutein has been shown to have antioxidant functions in newborns and with zeaxantin selectively taken up into the macula of the eye. We hypothesize that lutein administration may contribute to reducing the incidence of Retinopathy of Prematurity (ROP). This was a single center, double-blind randomized controlled study. Preterm infants with gestational age (GA) ≤32 weeks able to tolerate minimal enteral feeding before the seventh day of life (DOL) were enrolled; lutein and zeaxantin plasma concentrations and ROP occurrence and severity were evaluated. Sixty-three newborns were enrolled, 31 in the lutein group and 32 in the placebo group (one died before ROP assessment). The mean GA was 29.9 (±1.9) weeks and the mean birth weight was 1331 (±415) grams. There were no differences in the incidence of ROP at any stage between groups. Oxidative injury is probably an additional mechanism of damage of the developing retinal vessels, and it probably plays only a minor role in the pathogenesis of ROP. Supplementation with antioxidant substances might have beneficial effects noticeable only on larger samples of high risk neonates or at very high dosage. Further investigations would be needed to evaluate whether lutein supplementation can influence functional rather than anatomical outcomes in preterm infants.

Analysis of risk factors for progression to treatment-requiring ROP in a single neonatal intensive care unit: is the exposure time relevant?

Objective: Retinopathy of prematurity (ROP) is a multifactorial disease whose pathogenesis is organized in two phases. We hypothesized that postnatal risk factors may differently exert their effect in a phase dependent way. Methods: Data obtained from medical records of 93 very low birth weight neonates with stage ≥ 3 ROP were analyzed. Perinatal ROP risk factors were compared between infants with stage 3 ROP not requiring surgery and infants with treatment-requiring ROP with relation to newborn’s lifetime exposure. Results: In the first two weeks and in the whole first month of life length of oxygen administration was an independent risk factor for treatment-requiring ROP. In the first month of life also sepsis was identified as independent risk factor for surgical ROP. Sepsis and Candida pneumonia in the time frame from birth to ROP diagnosis and prolonged mechanical ventilation from diagnosis to prethreshold ROP were associated to treatment-requiring ROP. Blood transfusions are the only risk factor for treatment-requiring ROP identified in all the periods analyzed. Conclusion: Risk factors for ROP play their role since birth. Beside scrupulous oxygen-administration monitoring and prevention of infections, blood transfusions are of primary importance in the development of treatment-requiring ROP.

Remifentanil analgosedation in preterm newborns during mechanical ventilation

Aim:  To assess efficacy of remifentanil in preterm newborns during mechanical ventilation.

Sleep disorders in children with cerebral palsy: neurodevelopmental and behavioral correlates

OBJECTIVES We aimed to estimate the frequency of sleep disorders in children with cerebral palsy (CP) using the Sleep Disturbance Scale for Children (SDSC) and to evaluate the relations between sleep disorders and motor, cognitive, and behavioral problems. METHODS One hundred and sixty-five children with CP ages 6-16 years (mean age, 11years) were assessed using the SDSC, the Gross Motor Function Classification System (GMFCS), the Wechsler Intelligence Scale for Children and the Child Behavior Check List (CBCL) to assess sleep, motor, cognitive, and behavioral problems, respectively. RESULTS An abnormal total sleep score was found in 19% of children with CP; more than 40% of children had an abnormal score on at least one SDSC factor. The SDSC total score was significantly associated (P<.01) with mental retardation, epilepsy, CBCL scores, and level 5 on the GMFCS. CONCLUSIONS Our results confirm that sleep disorders are common in children with cerebral palsy. The relationship between motor and cognitive behavior and epilepsy should be further explored to better understand how these factors influence one another to identify effective treatments and to improve the well-being of the child.

Neonatal outcomes in triplet pregnancies: assisted reproduction versus spontaneous conception

Abstract Aims: The purpose of this study is to compare neonatal outcomes of spontaneously conceived triplets with triplets conceived by assisted reproduction. Methods: This was a retrospective cohort study of all cases from assisted triplet pregnancies and controls from spontaneous triplet pregnancies. A total of 24 triplet pregnancies were studied: six spontaneous and 18 assisted. The following variables were evaluated in all newborns: prematurity, birth-weight, small for gestational age, birth-weight discordance, Apgar scores, major neonatal morbidity and perinatal mortality. Results: Gestational age (33±1 vs. 33±2 weeks) and birth-weight (1760±256 vs. 1907±452 g) were similar in spontaneous and assisted triplet pregnancies. There were no significant differences in the rates of small for gestational age, discordance, and major neonatal morbidity. In the assisted reproduction group only the following cases were recorded: 1 surgically treated patent ductus arteriosus, 1 feto-fetal transfusion syndrome, 2 grade II intraventricular hemorrhage, 1 Cri du Chat syndrome and 1 stillbirth with malformations. Conclusions: This study is unable to assess the influence of assisted reproduction on the neonatal outcomes of triplet pregnancies. However, the results suggest that the incidence of major neonatal morbidity, especially malformations, might increase due to assisted reproduction. This finding requires further confirmation.

Cortical visual function in preterm infants in the first year.

OBJECTIVE To assess visual function in low-risk preterm infants at 3, 5, and 12 months corrected age to determine whether the maturation of visual function in the first year is similar to that reported in term-born infants. STUDY DESIGN Seventy-five low-risk infants (25.0-30.9 weeks gestation) underwent ophthalmological examinations and a battery of tests (fix and follow, visual fields, acuity, attention at distance, and fixation shift) designed to assess various aspects of visual function at 3, 5, and 12 months corrected age. RESULTS The results were comparable with normative data from term-born infants in all tests but fixation shift, suggesting that maturation of most aspects of visual function is not significantly affected by preterm birth. In contrast, >25% of preterm infants failed the fixation shift test at 3 months, with a higher percentage of failing at 5 and 12 months. CONCLUSIONS There is a specific profile of early visual behavior in low-risk preterm infants, with a high percentage of infants failing a test that specifically assesses visual attention and provides a measure of cortical processing.

Sleep disturbances in preschool age children with cerebral palsy: a questionnaire study

OBJECTIVES The study aimed to analyze (i) the prevalence of sleep disorders in pre-school children with cerebral palsy (CP) using the Sleep Disturbance Scale for Children (SDSC), (ii) the possible association with motor, cognitive and behavioral problems, and (iii) the possible differences with typically developing children matched for age and gender. METHODS One-hundred children with CP (age range: 3-5 years, mean: 3.8 years) were assessed using the SDSC, the Gross Motor Function Classification System (GMFCS), the Wechsler Preschool and Primary Scale of Intelligence, and the Child Behaviour Check List (CBCL) to assess sleep, motor, cognitive, and behavioral problems, respectively. Further 100 healthy children matched for age and sex were assessed using the SDSC. RESULTS An abnormal total sleep score was found in 13% of children with CP while 35% had an abnormal score on at least one SDSC factor. SDSC total score was significantly associated with pathological internalizing scores on CBCL and active epilepsy on multivariate analysis. CP group reported higher significant median scores on SDSC total, parasomnias, and difficulty in initiating and maintaining sleep factors. CONCLUSIONS In pre-school children sleep disorders are more common in children with CP than in healthy control group and are often associated with epilepsy and behavioral problems.