Kousiki Patra

Evaluating preterm infants with the Bayley-III: Patterns and correlates of development

This study investigates the Third Edition of the Bayley Scales of Infant and Toddler Development (Bayley-III) and: (1) early patterns of neurodevelopmental performance among preterm infants 8-12 months of age; and (2) correlations between known risk factors and neurodevelopmental outcome of preterm infants in this cohort. Mean Language Index (LI; 91±15) and Motor Index (MI; 94±17) were significantly lower than the Cognitive Index (CI; 102±15, p<.01). For the majority (53%) of infants, language development was their weakest domain; for another 39%, motor skills were the weakest area of development. Almost one-quarter (22%) of this cohort had mildly delayed language and motor skills, while 7% had significantly delayed language and motor skills. Regression models revealed severely abnormal head ultrasound significantly predicted MI, LI, and CI. Oxygen dependence at discharge predicted CI, LI, and race/ethnicity predicted LI, MI. Results support the addition of the Language Index to the newly revised Bayley-III Scales. Prediction models of developmental performance confirm known neonatal risk factors and reveal sociodemographic risk factors that call for additional research.

Depression, anxiety, and perinatal-specific posttraumatic distress in mothers of very low birth weight infants in the neonatal intensive care unit.

Objective: To compare the trajectories and determine the predictors of maternal distress defined as a continuous spectrum of symptomatology and elevated symptomatology, of depression, anxiety, and perinatal-specific posttraumatic stress (PPTS), in mothers of very low birth weight (VLBW) infants throughout the neonatal intensive care unit (NICU) hospitalization. Method: Sixty-nine mothers completed psychological questionnaires within the first month of their infants NICU hospitalization and again 2 weeks before NICU discharge. Multiple regression models determined maternal psychological, reproductive, sociodemographic, and infant medical predictors of maternal distress. Results: Perinatal-specific posttraumatic stress remained stable throughout the NICU hospitalization, whereas other aspects of distress declined. Previous psychological history and infant medical variables predicted higher PPTS but no other aspects of distress. Reproductive variables predicted anxiety and PPTS; history of fetal loss initially predicted lower PPTS but throughout hospitalization primipara status emerged as a predictor of higher anxiety and PPTS. Sociodemographic variables predicated initial, but not later, depressive distress. Conclusions: Psychological screening is important in the NICU. The PPTS profile suggests it may require distinct treatment. Primiparas should be targeted for intervention.

Evaluation of the relationship between opioid exposure in extremely low birth weight infants in the neonatal intensive care unit and neurodevelopmental outcome at 2 years

BACKGROUND Extremely low birth weight (ELBW) infants are exposed to many painful procedures while in the neonatal intensive care unit (NICU), such as catheter insertion and endotracheal intubation. Exposure of ELBW infants to repetitive pain and stress in the NICU can lead to cardiovascular instability and may alter neuronal and synaptic organization. Opioid analgesics are administered to reduce pain, stress and to potentially reduce poor neurologic outcomes. They may also be utilized as sedation for mechanically ventilated ELBW infants. There is limited data in regards to neurodevelopmental outcomes of preterm infants exposed to opioids, and available studies have conflicting results. OBJECTIVE To examine the relationship between cumulative opioid dose in ELBW infants in the NICU and neurodevelopmental outcomes at 20 months corrected age (CA). STUDY DESIGN 100 ELBW infants who had complete neurodevelopmental assessments at 20 months CA were categorized by cumulative opioid exposure during the NICU stay (high vs. low/no opioid). Outcome measures included cognitive, motor and language scores from the Bayley Scales of Infant and Toddler Development-III (BSITD-III). Multiple regression analyses adjusted for the impact of social and neonatal risk factors on outcome. RESULTS There were 60 patients with high and 40 with low/no opioid exposure. Infants in the high dose group had a higher number of median ventilator days (53.5 vs. 45.6 days, p=0.046) and a higher incidence of necrotizing enterocolitis (5% vs. 21.7%, p=0.022). There were no significant differences in BSITD-III scores between the two opiate groups. In multivariate analysis cumulative opioid dose was associated with lower cognitive scores on the BSITD-III even after adjusting for social and neonatal risk factors (β=-0.247, p=0.012). CONCLUSION Cumulative opioid dose is associated with worse cognitive scores at 20 months CA even after adjusting for social and neonatal risk factors.

Maternal psychological distress and visitation to the neonatal intensive care unit.

To examine associations between maternal neonatal intensive care unit (NICU) visitation rates, maternal psychological distress (‘distress’) and preterm infant outcome post‐NICU discharge in a contemporary cohort of very low birthweight (VLBW) infants.

Cardiorespiratory events in extremely low birth weight infants: neurodevelopmental outcome at 1 and 2 years

Objective:To examine the association between cardiorespiratory events (CRE) and neurodevelopmental (ND) outcome at 8 and 20 months corrected age (CA) in a contemporary extremely low birth weight (ELBW )cohort.Study Design:Retrospective chart review of 98 ELBW infants born in 2009 to 2010 who completed ND assessments at 8 and 20 months CA. Neonatal, sociodemographic, CRE and ND data were collected. ND outcome measures included neurologic examination and results from the Bayley Scales of Infant and Toddler Development-III. Multiple regression analyses adjusted for the impact of neonatal risk factors on ND outcome.Result:After adjusting for neonatal and social variables, greater frequency of CRE was related to worse language scores at 8 months, while CRE of greater severity were related to worse language at 20 months CA.Conclusion:CRE in ELBW infants have impact on language development in the first two years of life.

Part C early intervention utilization in preterm infants: Opportunity for referral from a NICU follow-up clinic.

OBJECTIVE Early Intervention (EI) services promote development for preterm infants. In the state of Illinois, Child and Family Connections (CFC) is the intake agency that determines qualification for EI services. In Illinois, all extremely low birth weight (ELBW) infants are eligible for and referred to CFC at discharge from the Neonatal Intensive Care Unit (NICU). This study investigated: (1) patterns of CFC and EI enrollment, and; (2) predictors of CFC enrollment, need for CFC referral, and high EI therapy use among preterm infants seen in a NICU follow-up clinic. METHODS 405 preterm infants, including 169 ELBW infants, were seen in a NICU follow-up clinic at 4-, 8- and 20-months corrected age. CFC/EI data were collected at each visit. Multiple regression analyses adjusted for the effect of medical, sociodemographic and neurodevelopmental risk factors on CFC/EI outcome. RESULTS Despite the high rate of EI utilization and routine care by primary pediatricians, up to 28% of ELBW infants required a CFC referral from a NICU follow-up clinic. Medical and neurodevelopmental risk factors were associated with CFC enrollment while medical, sociodemographic and neurodevelopmental risk factors were associated with need for CFC referral. CONCLUSION NICU follow-up clinics facilitate appropriate CFC/EI services for preterm infants.

Neurodevelopmental impact of hydrocortisone exposure in extremely low birth weight infants: outcomes at 1 and 2 years

Objective:Postnatal steroids are used in neonatal intensive care units despite known side effects. Hydrocortisone (HC) use persists as it is believed to have less deleterious effects on neurodevelopmental (ND) outcome compared to other steroids. The literature is sparse with respect to the ND impact of HC use in recent years. Hence, we sought to examine the effect of HC use on ND outcome in a contemporary cohort of extremely low birth weight (ELBW) infants.Study Design:A total of 175 ELBW infants (86 HC exposed, 89 steroid naive) born in 2008 to 2010 were compared for mortality, morbidity and ND outcome at 8 and 20 months corrected age. Outcome measures included neurologic exam and results of the Bayley Scales of Infant and Toddler Development-III (BSITD-III). Multiple regression analyses adjusted for the effect of other risk factors on outcome.Result:Overall, 65 (75%) of the HC and 74 (83%) of the no-HC groups survived to discharge. HC infants were smaller (mean birth weight (BW) 719±127 g vs 837±99 g) and of lower gestational age (GA) (mean GA 26.0±1.7 weeks vs 27.5±1.8 weeks) compared to the no-HC group. Patients in the HC group were more likely to be a multiple, have a severely abnormal head ultrasound, bronchopulmonary dysplasia, retinopathy of prematurity, necrotizing enterocolitis and receive treatment for patent ductus arteriosus and hypotension than those in the no-HC group. Of the HC group, the mean age at treatment was 20±19 days, mean duration of treatment 49±37 days. At 8 months, the HC group had lower mean motor (87±18 vs 95±15, P=0.028) and fine motor (9±2.9 vs 10.5±2.6, P=0.005) and higher rate of subnormal motor (44 vs 15%, P=0.002) and fine motor scores (24 vs 6.5%, P=0.017). In regression analyses, HC exposure >7 days was significantly related to worse outcome on fine motor scores at 8 months while cumulative days of HC exposure was a predictor of worse outcome on language at 8 months and motor outcome at 20 months. Each additional day of HC exposure increased the odds of subnormal receptive and expressive language in the first year of life by 4 and 2%, respectively, and increased odds of subnormal motor function by 2% in the 2nd year of life.Conclusion:HC exposure for >7 days is associated with worse performance in fine motor skills in the first year of life, while cumulative HC exposure negatively impacts receptive and expressive language skills in the first year and motor skills in the second year of life after adjusting for neonatal and social risk factors.

Parental perception of child vulnerability among mothers of very low birth weight infants: psychological predictors and neurodevelopmental sequelae at 2 years

Objective:The objective of this study was to examine the impact of maternal psychological distress on the development of parental perception of child vulnerability (PPCV) in mothers of very low birth weight (VLBW) infants; and to examine the impact of PPCV on neurodevelopmental outcome in VLBW infants in the second year of life.Study Design:This is a prospective study of 69 mothers and their VLBW infants recruited from 2011 to 2012 for whom maternal psychological data were collected during the neonatal intensive care unit (NICU) hospitalization. Maternal PPCV was assessed at 4 months corrected age (CA). Neurodevelopmental outcome was assessed at 20 months CA. Regression analyses modeled the development of PPCV and the impact of PPCV on neurodevelopmental outcome.Results:PPCV at 4 months CA was predicted by maternal anxiety and history of previous fetal loss reported during the NICU stay. Higher PPCV at 4 months CA was associated with lower language scores at 20 months CA.Conclusion:Targeted interventions aimed at reducing PPCV in the NICU are supported.

Discharge without alarm(s)

One of the hallmark criteria for discharge of any preterm infant, particularly for those of very low birth weight (VLBW), from the Neonatal Intensive Care Unit (NICU) is the successful completion of an apnea and bradycardia ‘countdown.’ The margin of safety for an apnea-free countdown, however, remains controversial despite the longstanding recommendations to standardize management strategies. Although apnea of prematurity is one of the most common diagnoses in the NICU, there remains to this day a lack of consensus on the definition of a ‘clinically significant event’ as well as substantial practice variation with respect to ‘reasonable inpatient monitoring’ of these infants. These dilemmas are a source of frustration not only for the neonatal healthcare team, but also for families of these infants, for whom recurrent apnea/bradycardia events are a source of immense anxiety both during and after the initial NICU hospitalization. The Committee on Fetus and Newborn’s Clinical Report on Apnea of Prematurity encourages each NICU to develop their own policies and procedures to address the issues surrounding caregiver assessment, intervention and documentation of apnea/bradycardia/desaturation events and the duration of the period of observation before discharge. Nevertheless, there are few published studies that document successful implementation of a standardized protocol. In this month’s Journal of Perinatology, Chandrasekharan et al. report on the impact of implementation of a standardized institutional protocol for monitoring apnea and bradycardia events in VLBW infants. The protocol’s focus was on standardization of the duration of observation for apnea/bradycardia/ desaturation events in preterm infants who were otherwise ready for discharge and the study specifically examined the impact of this protocol on NICU length of stay and hospital readmission within 30 days after discharge from the NICU. This was a large contemporary cohort of VLBW infants born before (n= 426, 2011–2013) and after (n= 369, 2014–2016) the initiation of an algorithm that categorized apnea/bradycardia/events according to severity and need for intervention (apnea with need for stimulation, apnea without need for stimulation and without bradycardia or desaturation, bradycardia with and without stimulation, isolated bradycardia or desaturation events) with corresponding pathways of observation until discharge. The group is to be commended for their ability to achieve the collaboration essential to the success of any protocol implementation, with 34 providers agreeing on the criteria for the protocol, commitment to utilizing said criteria and supporting the nursing staff through 3 months of education. With these definitions in place, inter-provider variability improved and there was a subsequent significant reduction in the duration of observation of apnea spells from 8 (6–10) days to 7 (6–8) days, as well as bradycardic spells from 6 (5–9) days to 5 (5–7) days. Interestingly, despite this improvement, the overall length of NICU stay did not significantly change, which may speak to the influence of other morbidities, such as bronchopulmonary dysplasia, which occurred at higher rates in infants born during the last study year. It may be that any reduction of length of stay due to reduced observation period for apnea/bradycardia events was offset by time needed to achieve oral feedings and/or to wean from a nasal cannula. Conversely, documented hospital readmission rate decreased after implementation of the protocol despite no significant clinical differences between the two cohorts. As the authors acknowledge, implementation of the apnea/bradycardia protocol and the intensive staff education may have led to increased family education, satisfaction and overall confidence in caring for their infants, which could have decreased healthcare utilization post discharge. However, this study did not document caregiver roles/education/visitation rates pre and post implementation nor adjust for socioeconomic variables between the cohorts that could have confounded these results. There are a number of controversies regarding apnea/bradycardia management that are highlighted in this study. Caffeine use was limited and most likely would not affect the length of stay. The availability of apnea monitors also can result in altering discharge practice and also requires a standardized protocol to identify appropriate infants and resources. The practice of continued pulse oximetry monitoring up until discharge in the convalescing preterm infant may be difficult to justify without understanding the outcome of intermittent desaturations, particularly for those that occur with feedings. Chandrasekharan et al. raise important question for the daily practice of neonatology: What is the correct algorithm for monitoring our most vulnerable but convalescing patients? What should be considered a clinically significant event? Furthermore, how many apnea/bradycardia events are ‘too severe’ or ‘too many in number’ to accept? Should length of stay and hospital readmission be our quality indicators for this morbidity or should it be neurodevelopmental outcome at a defined point in time? This study challenges other NICUs to consider the impact of creating an algorithm of their own during a time when there is controversy on the validity of nursing documentation of events versus electronic monitor downloads as well as implementation of practice changes as many NICUs transition from open bay to single room environments. Nevertheless, this study speaks to successful protocol development, implementation and examination of outcome measures, all of which can guide other NICUs to establish their own best practices in the management of apnea and bradycardias of prematurity and to discharge without alarm.