J. Colin Partridge

Serial quantitative diffusion tensor MRI of the premature brain: development in newborns with and without injury.

To determine the change over time of the apparent diffusion coefficient (ADC) and relative anisotropy of cerebral water in a cohort of premature newborns serially studied near birth and again near term.

Barriers to Palliative Care for Children : Perceptions of Pediatric Health Care Providers

OBJECTIVE. The goal was to explore barriers to palliative care experienced by pediatric health care providers caring for seriously ill children. METHODS. This study explored pediatric provider perceptions of end-of-life care in an academic childrens hospital, with the goal of describing perceived barriers to end-of-life care for children and their families. The report focuses on the responses of nurses (n = 117) and physicians (n = 81). RESULTS. Approximately one half of the respondents reported 4 of 26 barriers listed in the study questionnaire as frequently or almost always occurring, that is, uncertain prognosis (55%), family not ready to acknowledge incurable condition (51%), language barriers (47%), and time constraints (47%). Approximately one third of respondents cited another 8 barriers frequently arising from problems with communication and from insufficient education in pain and palliative care. Fourteen barriers were perceived by >75% of staff members as occasionally or never interfering with pediatric end-of-life care. Comparisons between physicians and nurses and between ICU and non-ICU staff members revealed several significant differences between these groups. CONCLUSIONS. Perceived barriers to pediatric end-of-life care differed from those impeding adult end-of-life care. The most-commonly perceived factors that interfered with optimal pediatric end-of-life care involved uncertainties in prognosis and discrepancies in treatment goals between staff members and family members, followed by barriers to communication. Improved staff education in communication skills and palliative care for children may help overcome some of these obstacles, but pediatric providers must realize that uncertainty may be unavoidable and inherent in the care of seriously ill children. An uncertain prognosis should be a signal to initiate, rather than to delay, palliative care.

Clinical signs predict 30-month neurodevelopmental outcome after neonatal encephalopathy

OBJECTIVE This study was undertaken to determine the value of a neonatal encephalopathy score (ES) and the presence of seizures for predicting 30-month neurodevelopmental outcome. STUDY DESIGN In a cohort study, 68 term newborn infants with encephalopathy were evaluated with an ES based on alertness, feeding, tone, respiratory status, reflexes, and seizure activity (range: 0-6). Seizures were noted as present or absent clinically. Significant cognitive deficits (Mental Development Index <70), motor disability (spastic triplegia/quadriplegia), or death were abnormal outcomes. RESULTS Twenty-two newborn infants (32%) had abnormal outcomes. With the use of maximum ES and presence of seizures from days 1 to 3 of life, 87% of newborn infants were correctly classified (area under receiver operating curve 0.93). By using ES and presence of seizures on day 1 only, 87% of newborn infants were correctly classified (area under receiver operating curve 0.89). CONCLUSION The severity of neonatal encephalopathy and the presence of seizures are valuable predictors of 30-month neurodevelopmental outcome, as early as the first day of life.

Optimal timing for diagnostic cranial ultrasound in low-birth-weight infants: Detection of intracranial hemorrhage and ventricular dilation

Intracranial hemorrhage and posthemorrhagic ventricular dilation are common problems in small preterm infants. To determine the optimal timing for ultrasound diagnosis of these abnormalities, we studied 64 preterm infants (less than 1,500 gm) by sequential cranial ultrasonography from birth until one year of age or until death. The optimal timing for ultrasound diagnosis of intracranial hemorrhage is days 4 to 7 with follow-up at day 14. The most efficient time for ultrasound examination to diagnose ventricular dilation was day 14 with follow-up at 3 months. Intracranial hemorrhage was diagnosed by ultrasound in 35 of the 64 patients (55%). In 18 of the 64 infants (28%) significant ventricular dilation was diagnosed by ultrasound during the first three months.

Predictors of 30-month outcome after perinatal depression: role of proton MRS and socioeconomic factors.

The objective was to determine in infants with perinatal depression whether the relative concentrations of N-acetylaspartate and lactate in the neonatal period are associated with (1) neurodevelopmental outcome at 30 mo of age or (2) deterioration in outcome from age 12 to 30 mo; and to determine whether socioeconomic factors are associated with deterioration in outcome. Thirty-seven term neonates were prospectively studied with single-voxel proton magnetic resonance spectroscopy of the basal nuclei and intervascular boundary zones. Thirty-month outcomes were classified as normal [if Mental Development Index of the Bayley Scales of Infant Development (MDI) >85 and neuromotor scores (NMS) <3;n = 15], abnormal [if MDI ≤85 and/or NMS ≥3 at 12 and 30 mo;n = 11], or deteriorated [if normal at 12 mo and abnormal at 30 mo (MDI ≤85 or NMS ≥3);n = 11]. Thirty percent (11/37) of our cohort deteriorated between 12 and 30 mo. N-acetylaspartate/choline decreased across the groups ordered as normal, deteriorated, and abnormal [in basal nuclei (p ≤ 0.001) and intervascular boundary zones (p = 0.04)], but was not different between the normal and deteriorated groups (p = 0.08). Lactate/choline similarly increased across the groups [in basal nuclei (p = 0.01) and intervascular boundary zones (p = 0.05)]. The odds of deterioration, if normal at 12 mo, increased by a factor of 5.1 (95% confidence interval: 1.3–19.8) with each decrease in one of four household income strata. Infants with perinatal depression are at high risk of developmental deterioration between 12 and 30 mo of age, particularly if in a lower income home or with intermediate values of cerebral metabolites on neonatal proton magnetic resonance spectroscopy.

Encephalopathy as a predictor of magnetic resonance imaging abnormalities in asphyxiated newborns

Basal ganglia abnormalities on magnetic resonance imaging predict neurodevelopmental impairment in newborns with perinatal depression. We determined the value of a clinical encephalopathy score as a predictor of abnormal magnetic resonance imaging results in newborns with perinatal depression. We assigned a neonatal encephalopathy score to 101 newborns. The encephalopathy score, based on alertness, feeding, tone, respiratory status, reflexes, and seizure activity, was assigned once daily. The maximum score from the first 3 days of life was compared with abnormal magnetic resonance imaging results present globally or solely in the basal ganglia.Eighty-one percent of patients manifested abnormalities on any magnetic resonance imaging sequence, and 37% manifested abnormalities in the basal ganglia alone. The encephalopathy score correlated well with magnetic resonance imaging abnormalities in the basal ganglia (Spearman Rho = 0.335, P < 0.0001). Newborns with mild and severe encephalopathy had likelihood ratios of 0.41 and 7.4, respectively, for abnormal basal ganglia magnetic resonance imaging results. Newborns with moderate encephalopathy (composing 47% of the cohort) manifested basal ganglia abnormalities with a likelihood ratio of 0.785. Severe clinical encephalopathy correlates with abnormal basal ganglia magnetic resonance imaging results, and mild encephalopathy correlates with a normal magnetic resonance imaging result. However, standard clinical criteria do not alter the prior risk of abnormal basal ganglia magnetic resonance imaging results for newborns with moderate encephalopathy.

Diminished White Matter Injury over Time in a Cohort of Premature Newborns

OBJECTIVES To determine the rate of magnetic resonance imaging (MRI)-detected noncystic white matter injury (WMI) in a prospective cohort of premature newborns, and to evaluate its associations with changes in clinical predictors of WMI over the study period. STUDY DESIGN A prospective cohort of premature newborns (<33 weeks gestational age) was studied with MRI within 4 weeks of birth and near term-equivalent age. A pediatric neuroradiologist scored the severity of WMI on T1-weighted MRI according to published criteria. WMI was classified as none/mild or moderate/severe. Subjects with severe cystic WMI, periventricular hemorrhagic infarction, or motion artifact on MRI were excluded. Changes in clinical characteristics and predictors of WMI over the study period (1998-2011) were evaluated. Predictors of moderate/severe WMI, including birth year, were evaluated using multivariate logistic regression. RESULTS Among 267 newborns, 45 (17%) had moderate/severe WMI. The rate of moderate/severe WMI decreased over the study period (P = .002, χ(2) test for trends). On multivariate logistic regression, the odds of moderate/severe WMI decreased by 11% for each birth year of the cohort (OR, 0.89; 95% CI, 0.81-0.98; P = .02). Prolonged exposure to indomethacin also was independently associated with reduced odds of moderate/severe WMI. CONCLUSION The decreasing burden of MRI-detected moderate/severe noncystic WMI in our cohort of premature newborns is independent over time of changes in the known clinical predictors of WMI. Prolonged exposure to indomethacin is associated with reduced WMI.

Lymphocyte abnormalities in infants born to drug-abusing mothers

To evaluate the possible effects of maternal intravenous drug use on infant immunity, we measured the in vitro peripheral blood mononuclear cell proliferative responses to phytohemagglutinin (PHA) and pokeweed mitogen, T cell subset numbers, immunoglobulin levels, and titers of antibodies to cytomegalovirus (CMV) and human immunodeficiency virus (HIV) in a group of drug-abusing mothers and their infants. Infants of drug abusers had a lower proliferative response to mitogen, associated with altered kinetics of the maximum response to PHA. The OKT4/OKT8 ratio decreased with age in the drug-exposed infants compared with control infants (P less than 0.005). There was no evidence of CMV infection in either group. One mother and her infant had antibody to HIV. Our data demonstrate that infants of intravenous drug-using mothers have distinct immunologic differences at birth compared with non-drug-exposed infants and that these persist throughout the first year of life. The cause appears unrelated to intrauterine viral infection, suggesting a direct toxic effect of the drugs on fetal immunologic development.

Persistent Pulmonary Hypertension of the Newborn in Late Preterm and Term Infants in California

BACKGROUND AND OBJECTIVES: There are limited epidemiologic data on persistent pulmonary hypertension of the newborn (PPHN). We sought to describe the incidence and 1-year mortality of PPHN by its underlying cause, and to identify risk factors for PPHN in a contemporary population-based dataset. METHODS: The California Office of Statewide Health Planning and Development maintains a database linking maternal and infant hospital discharges, readmissions, and birth and death certificates from 1 year before to 1 year after birth. We searched the database (2007–2011) for cases of PPHN (identified by International Classification of Diseases, Ninth Revision codes), including infants ≥34 weeks’ gestational age without congenital heart disease. Multivariate Poisson regression was used to identify risk factors associated with PPHN; results are presented as risk ratios, 95% confidence intervals. RESULTS: Incidence of PPHN was 0.18% (3277 cases/1 781 156 live births). Infection was the most common cause (30.0%). One-year mortality was 7.6%; infants with congenital anomalies of the respiratory tract had the highest mortality (32.0%). Risk factors independently associated with PPHN included gestational age <37 weeks, black race, large and small for gestational age, maternal preexisting and gestational diabetes, obesity, and advanced age. Female sex, Hispanic ethnicity, and multiple gestation were protective against PPHN. CONCLUSIONS: This risk factor profile will aid clinicians identifying infants at increased risk for PPHN, as they are at greater risk for rapid clinical deterioration.

Pain During Mogen or PlastiBell Circumcision

Routine neonatal circumcision can be a painful procedure. Although analgesia for circumcision has been studied extensively, there are few studies comparing which surgical technique may be associated with the least pain and discomfort when carried out by pediatric trainees.OBJECTIVE: We studied two commonly used techniques for circumcision to determine which was associated with less pain and discomfort.STUDY DESIGN: In a randomized, prospective, but not blinded study, newborns were circumcised either by Mogen clamp or by PlastiBell. All received dorsal nerve blocks with lidocaine. Fifty-nine well, term, newborn infants at San Francisco General Hospital were studied from 1997 to 1998. Circumcisions were carried out mostly by interns and residents in family practice and pediatrics. Pain was assessed by measuring duration of the procedure and by a simple behavioral score done sequentially.RESULTS: Dorsal nerve blocks were judged to be fully effective in over 70% of cases. Neither Mogen nor PlastiBell was associated with greater pain per 3-minute time period, but the PlastiBell technique on average took nearly twice as long as the Mogen procedure (20 vs 12 minutes). We judged that 60% of the infants had pain or discomfort associated with the procedure that was excessive. Residents and interns universally preferred the Mogen technique over the PlastiBell because of the formers simplicity.CONCLUSION: During the procedure, Mogen circumcision is associated with less pain and discomfort, takes less time, and is preferred by trainees when compared with the PlastiBell.