Leslie Caldarelli

Just, in Time: Ethical Implications of Serial Predictions of Death and Morbidity for Ventilated Premature Infants

OBJECTIVES. For a cohort of extremely premature, ventilated, newborn infants, we determined the power of either serial caretaker intuitions of “die before discharge” or serial illness severity scores to predict the outcomes of death in the NICU or neurologic performance at corrected age of 2 years. METHODS. We identified 268 premature infants who were admitted to our NICU in 1999–2004 and required mechanical ventilation. For each infant on each day of mechanical ventilation, we asked nurses, residents, fellows, and attending physicians the following question: “Do you think this child is going to live to go home or die before hospital discharge?” In addition, we calculated illness severity scores until either death or extubation. RESULTS. A total of 17066 intuition profiles were obtained on 5609 days of mechanical ventilation in the NICU. One hundred (37%) of 268 profiled infants had ≥1 intuition of die before discharge. Only 33 infants (33%) with an intuition of die actually died in the NICU. Of 48 infants with even 1 day of corroborated intuition of die in the NICU, only 7 (14%) were alive with both Mental Developmental Index and Psychomotor Developmental Index scores of >69, and only 2 (4%) were alive with both Mental Developmental Index and Psychomotor Developmental Index Scores of >79 at corrected age of 2 years. On day of life 1, the Score for Neonatal Acute Physiology II value for nonsurvivors (38.2 ± 18.1) was significantly higher than that for survivors (26.3 ± 12.7). However, this difference decreased steadily over time as scores improved for both groups. CONCLUSIONS. Illness severity scores become progressively less helpful over time in distinguishing infants who will either die in the NICU or survive with low Mental Developmental Index/Psychomotor Developmental Index scores. Serial caretaker intuitions of die before discharge also fail to identify prospective nonsurviving infants. However, corroborated intuitions of die before discharge identify a subset of infants whose likelihood of surviving to 2 years with both MDI and PDI >80 is approximately 4%.

Video and CD-ROM as a Training Tool for Performing Neurologic Examinations of 1-Year-Old Children in a Multicenter Epidemiologic Study

In lieu of traditional training of examiners to identify cerebral palsy on a neurologic examination at age 1 year, we proposed an alternative approach using a multimedia training video and CD-ROM we developed after a two-step validation process. We hypothesized that use of CD-ROM interactive training will lead to reliable and valid performance of the neurologic examination by both pediatric neurologists and nonpediatric neurologists. All examiners were asked to take one of six interobserver variability tests found on the CD-ROM on two occasions. In the first interobserver variability evaluation, 89% (531 of 594) of the responses agreed with the gold standard responses. Following annotated feedback to the examiners about the two items that had a 60% correct rate, the correct response rate rose to 93% (114 of 123). In the second interobserver variability evaluation, 88% (493 of 560) of the responses agreed with the gold standard responses. Following annotated feedback to the examiners about the four items that had a 70% correct rate, the correct response rate rose to 96% (104 of 108). Interactive CD-ROM examination training is an efficient and cost-effective means of training both neurologists and non-neurologists to perform structured neurologic examinations in 1-year-old children. It provides an effective means to evaluate interobserver variability, offers a route for feedback, and creates an opportunity to reevaluate variability, both immediately and at periodic intervals. (J Child Neurol 2005;20:829—831).

Evaluation of the Direct Antiglobulin (Coombs') Test for Identifying Newborns at Risk for Hemolysis as Determined by End-Tidal Carbon Monoxide Concentration (ETCOc); and Comparison of the Coombs' Test With ETCOc for Detecting Significant Jaundice

OBJECTIVE: First, to determine the sensitivity, specificity, and positive predictive value (PPV) of the direct antiglobulin test (DAT) for significant hemolysis in the neonate, as referenced to end-tidal carbon monoxide, the criterion standard for estimating the rate of hemolysis; and second, to evaluate the predictive value of the two procedures for significant jaundice.DESIGN: Consecutive term newborns admitted to the nursery of an inner-city university hospital over a 15-week period. DAT screening by the Blood Bank was performed on all. End-tidal carbon monoxide levels were obtained at 12±6 and at 24±6 hours of age. Infants of nonsmoking mothers whose 12-hour exhaled carbon monoxide level was ≥95th percentile were defined as having significant hemolysis.RESULTS: n=660; DAT was positive in 23 (3.5%). Using the 12-hour end-tidal carbon monoxide ≥3.2 μl/l (≥95th percentile) as reference (n=499 nonsmokers), the sensitivity of the DAT was 38.5% (10 of 26) and specificity 98.5% (466 of 473) for the detection of significant hemolysis. The PPV of the DAT for significant hemolysis at 12 hours was 58.8% (10 of 17). For significant jaundice the PPV of end-tidal carbon monoxide was greater than that for DAT (65.4% vs 52.9%), although not statistically so (p=0.25). The negative predictive values were similar.CONCLUSION: DAT fails to identify over half of the cases of significant hemolysis that are diagnosed by end-tidal carbon monoxide. A neonate with a positive DAT has about a 59% chance of having significant hemolysis. End-tidal carbon monoxide may also provide a more sensitive index for predicting significant jaundice.

Have the boundaries of the ‘grey zone’ of perinatal resuscitation changed for extremely preterm infants over 20 years?

To determine the boundaries of the grey zone of discretionary resuscitation over the past 20 years.

Common Symptoms, but Rare Diagnoses in Neonatology.

In this issue of Pediatric Annals, the articles discuss newborns who present with common neonatal symptomology, but have rare diagnostic outcomes. In the first article, Drs. Alison Chu and Harvey K. Chiu discuss tachypnea and hypoglycemia, commonly presenting symptoms during the newborn period. In the illustrated case, the early and persistent hypoglycemia was a clue to the newborn’s underlying endocrinopathy, a known risk factor for necrotizing enterocolitis in a full-term newborn. In the next article, Dr. Theodore De Beritto and colleagues present an article discussing a vein of Galen arteriovenous malformation. The authors describe a newborn delivered secondary to decreased fetal movements, decreased fetal heart rate variability, and late decelerations. After delivery, the newborn had unusual physical findings including bilateral neck swelling, a varicosity over the left carotid area, a fontanel with a bruit, and an active precordium. Next, Dr. Joyce Woo and colleagues discuss tachycardia in a newborn. Tachycardia in the fetus that persists in the newborn period warrants prompt evaluation. A lack of treatment can result in up to a 20% mortality rate. The most common causes of fetal and neonatal tachycardia are sinus tachycardia and supraventricular tachycardia. The final article, by Dr. Owais A. Khan and colleagues, describes acute renal failure (ARF) in the neonate. Their illustrative case details a neonate with ARF secondary to renal vein thrombosis, which is an unusual cause of intrinsic ARF that can be serious, often leading to a need for dialysis. Neonatal symptomology often leads to common neonatal diagnoses. In the articles presented in this issue, the common symptoms of tachypnea, hypoglycemia, fetal distress, tachycardia, and the signs of acute renal failure ultimately lead the physicians to much less common diagnoses.