Howard Needelman

Developmental outcomes of children with congenital diaphragmatic hernia: a multicenter prospective study.

PURPOSE To determine developmental outcomes and associated factors in patients with congenital diaphragmatic hernia (CDH) at 2 years of age. METHODS This is a multicenter prospective study of a CDH birth cohort. Clinical and socioeconomic data were collected. Bayley Scales of Infant Development (BSID-III) and Vineland Adaptive Behavior Scales (VABS-II) were performed at 2 years of age. RESULTS BSID-III and VABS-II assessments were completed on 48 and 49 children, respectively. The BSID-III mean cognitive, language, and motor scores were significantly below the norm mean with average scores of 93 ± 15, 95 ± 16, and 95 ± 11. Ten percent (5/47) scored more than 2 standard deviations below the norm on one or more domains. VABS-II scores were similar to BSID-III scores with mean communication, daily living skills, social, motor, adaptive behavior scores of 97 ± 14, 94 ± 16, 93 ± 13, 97 ± 10, and 94 ± 14. For the BSID-III, supplemental oxygen at 28 days, a prenatal diagnosis, need for extracorporeal membrane oxygenation (ECMO) and exclusive tube feeds at time of discharge were associated with lower scores. At 2 years of age, history of hospital readmission and need for tube feeds were associated with lower scores. Lower socioeconomic status correlated with lower developmental scores when adjusted for significant health factors. CONCLUSION CDH patients on average have lower developmental scores at 2 years of age compared to the norm. A need for ECMO, oxygen at 28 days of life, ongoing health issues and lower socioeconomic status are factors associated with developmental delays.

Effects of Postnatal Dexamethasone Exposure on the Developmental Outcome of Premature Infants

Extremely low birth weight premature infants are at risk for poor neurodevelopmental outcome. Postnatal dexamethasone has often been used in premature infants to prevent or treat bronchopulmonary dysplasia, and this drug is thought by some to affect neurodevelopmental outcome. We retrospectively examined the effect of this steroid on early neurodevelopment. Dexamethasone exposure was associated with an adverse outcome and was a stronger predictor of outcome than other accepted risk factors. If used, dexamethasone should be used in these high-risk infants for as short a period as possible.

Bayley Scales of Infant Development Screening Test-Gross Motor Subtest: efficacy in determining need for services.

Purpose: To identify the efficacy of the Bayley Scales of Infant and Toddler Development, Third Edition (BSID-III), Screening Test–Gross Motor Subtest (GMS) in identifying infants who are accepted for early intervention services. Methods: This retrospective study included 93 infants with a neonatal intensive care experience who participated in a 6-month developmental assessment follow-up visit. All infants were examined using the BSID-III Screening Test–GMS and the Alberta Infant Motor Scale. A binary logical regression analysis was used to determine the best predictors of acceptance status in this sample. Results: The BSID-III Screening Test–GMS accounted for a significant portion of the variance in acceptance status. Conclusion: The results suggest that the BSID-III Screening Test–GMS has great applicability for transdisciplinary/interdisciplinary teams as it effectively identified children who were eligible for early intervention.

The Effect of Hydrocortisone on Neurodevelopmental Outcome in Premature Infants Less than 29 Weeks' Gestation

The use of postnatal dexamethasone in premature newborns can be associated with a deleterious neurodevelopmental outcome. The effect of hydrocortisone on developmental outcome in these patients is less clear. We therefore sought to examine the effect of hydrocortisone on early developmental outcome in premature newborns. We retrospectively examined the effect of hydrocortisone on developmental outcome during the first 2 years of life in premature infants <29 weeks’ gestation at birth. Even though hydrocortisone was used in infants with a greater risk for poor outcome, its use, unless prolonged >7 days, was generally not associated with a worse developmental outcome or higher rate of referral for early intervention. A short course of hydrocortisone in sick premature newborns does not appear to have a deleterious effect on developmental outcome.

Building a System of Child Find Through a 3-Tiered Model of Follow-Up

Developmental TIPS (Tracking Infants Progress Statewide) is a project that performs statewide developmental follow-up of infants from the major neonatal intensive care units throughout Nebraska. Developmental TIPS enrolls infants who were in the neonatal intensive care unit for at least 48 hours, regardless of the childs perceived risk for neurodevelopmental disability. The goals of this program of developmental tracking are to standardize the system of follow-up in the state and to gather outcome data on this population of young children. This project supports parent-child interactions and promotes the childs health and safety within the context of universal screening and monitoring. It is a collaborative project among hospitals, the Nebraska Department of Education, the Nebraska Health and Human Services Division, local health and education providers, and families. The results suggest a high rate of referrals for low-, moderate-, and high-risk infants. This follow-up system has helped to support the Child Find efforts of the state by providing ongoing screening that maximizes early identification of developmental problems. The purpose of this article is to describe this comprehensive follow-up model that is an integral part of the state Child Find system and to report on the children being followed.

Neurodevelopmental Outcomes in Infants after Surgery for Congenital Heart Disease: A Comparison of Single‐Ventricle vs. Two‐Ventricle Physiology

INTRODUCTION The neurodevelopmental outcome of children with repaired congenital heart defect has risen in importance with improved survival. This study compares neurodevelopmental outcomes of children who had CHD with single ventricle physiology with those who had CHD with two-ventricle physiology. PATIENTS AND METHODS Participants included 112 infants discharged from the NICU between February 1999 to August 2006. The 12 infants who had a known genetic defect were excluded. Of the 100 infants 26 had single ventricle physiology and 74 had CHD with two-ventricle physiology. The children were seen in a follow-up clinic and growth parameters and standardized instruments were used to evaluate development. The referral rate to early intervention services was also compared. RESULTS The number of functional ventricles did not significantly differentiate growth parameters at 6-8 months of age. Early cognitive outcomes were relatively unimpaired in both the groups (single ventricle vs. two ventricle physiology). Early motor outcomes were worse in (p < 0.05) CHD with single ventricle physiology. The rate of referral for early intervention services was high in both groups compared to the average rate of referral in the state, but there was not a significant difference between the CHD groups. CONCLUSION Significant differences noted on motor outcomes at the 6-8 month visit were no longer apparent in later visits. Referral to early intervention services is high in both the groups. These findings are important to those caring for infants with CHD because many of these patients may need referral for early intervention.

Assisted Reproduction Versus Spontaneous Conception: A Comparison of the Developmental Outcomes in Twins

The use of assisted reproductive technology is increasing rapidly. Research, although sparse, has resulted in inconsistent findings as to the developmental prognosis for infants conceived by assisted reproductive techniques such as in vitro fertilization and the use of fertility drugs. In the present study, the authors compared twins who were spontaneously conceived with those who were conceived through assisted reproductive technology. The authors found differences in birth weight and gestational age. Infants conceived by assisted reproductive technology fared worse than did those who were spontaneously conceived. The authors found no differences between the groups in mental development at 24 months of age, but they found evidence of differences in physical development. Implications of the findings are discussed.

Effect of Community Size on Eligibility for Early Intervention for Infants With a Neonatal Intensive Care Experience

PURPOSE To determine if population density (rural vs urban) in a childs home community influenced the decision of eligibility for early intervention (EI) services. METHODS The sample included 356 infants with a gestational age of <31 weeks referred from a statewide child find program for an evaluation for EI services. A binary logistic regression analysis was completed to determine which variables predicted acceptance into EI services. FINDINGS Infants less than 31 weeks gestation residing in rural areas were more likely to be eligible for EI services than premature infants (ie, <31 weeks gestation) with similar birth characteristics from urban areas. A binary logistic regression analysis revealed an odds ratio for eligibility for EI services among children living in rural areas compared to those living in urban areas was 3.007 (95% CI, 1.497 to 6.040). Additionally, the odds ratio for eligibility for males as compared to females was 1.908 (95% CI, 1.017 to 3.578). Participants who lived in a rural area and were male were more likely to be eligible for EI services than those who lived in urban locations and were female. CONCLUSIONS Factors such as community support, experience with high-risk populations, and differences in interpreting eligibility criteria may influence the differences found between the rural and urban populations. Analysis of intervention cost versus effectiveness will be needed to determine whether the system as adopted in the rural versus urban environment is more appropriate for the provision of EI services.

Postterm Closure of the Cavum Septi Pellucidi and Developmental Outcome in Premature Infants

The authors report the natural history of closure of the cavum Septi pellucidi in premature infants 26 to 27 weeks postconception at birth and compare the developmental outcome in these infants who had closure by 42 weeks postconception to those who still had a cavum septum pellucidi visualized on ultrasound at approximately term (35-42 weeks). Of 72 patients, 35 patients still had a cavum septum pellucidi visualized on the last ultrasound done between 35 and 42 weeks postconception, and the developmental outcome of these patients was no different from those with earlier closure. The authors conclude that persistence of a cavum septi pellucidi through term is not an independent risk factor for developmental delay.

A definition of gentle ventilation in congenital diaphragmatic hernia: a survey of neonatologists and pediatric surgeons.

Abstract Ventilation practices have changed significantly since the initial reports in the mid 1980 of successful use of permissive hypercapnia and spontaneous ventilation [often called gentle ventilation (GV)] in infants with congenital diaphragmatic hernia (CDH). However, there has been little standardization of these practices or of the physiologic limits that define GV. We sought to ascertain among Diaphragmatic Hernia Research and Exploration; Advancing Molecular Science (DHREAMS) centers’ GV practices in the neonatal management of CDH. Pediatric surgeons and neonatologists from DHREAMS centers completed an online survey on GV practices in infants with CDH. The survey gathered data on how individuals defined GV including ventilator settings, blood gas parameters and other factors of respiratory management. A total of 87 respondents, from 12 DHREAMS centers completed the survey for an individual response rate of 53% and a 92% center response rate. Approximately 99% of the respondents defined GV as accepting higher carbon dioxide (PCO2) and 60% of the respondents also defined GV as accepting a lower pH. There was less consensus about the use of sedation and neuromuscular blocking agents in GV, both within and across the centers. Acceptable pH and PCO2 levels are broader than the goal ranges. Despite a lack of formal standardization, the results suggest that GV practice is consistently defined as the use of permissive hypercapnia with mild respiratory acidosis and less consistently with the use of sedation and neuromuscular blocking agents. GV is the reported practice of surveyed neonatologists and pediatric surgeons in the respiratory management of infants with CDH.