Meredith Ward

Neonatal Abstinence Syndrome and High School Performance

BACKGROUND AND OBJECTIVES: Little is known of the long-term, including school, outcomes of children diagnosed with Neonatal abstinence syndrome (NAS) (International Statistical Classification of Disease and Related Problems [10th Edition], Australian Modification, P96.1). METHODS: Linked analysis of health and curriculum-based test data for all children born in the state of New South Wales (NSW), Australia, between 2000 and 2006. Children with NAS (n = 2234) were compared with a control group matched for gestation, socioeconomic status, and gender (n = 4330, control) and with other NSW children (n = 598 265, population) for results on the National Assessment Program: Literacy and Numeracy, in grades 3, 5, and 7. RESULTS: Mean test scores (range 0–1000) for children with NAS were significantly lower in grade 3 (359 vs control: 410 vs population: 421). The deficit was progressive. By grade 7, children with NAS scored lower than other children in grade 5. The risk of not meeting minimum standards was independently associated with NAS (adjusted odds ratio [aOR], 2.5; 95% confidence interval [CI], 2.2–2.7), indigenous status (aOR, 2.2; 95% CI, 2.2–2.3), male gender (aOR, 1.3; 95% CI, 1.3–1.4), and low parental education (aOR, 1.5; 95% CI, 1.1–1.6), with all Ps < .001. CONCLUSIONS: A neonatal diagnostic code of NAS is strongly associated with poor and deteriorating school performance. Parental education may decrease the risk of failure. Children with NAS and their families must be identified early and provided with support to minimize the consequences of poor educational outcomes.

Targeted Oxygen in the Resuscitation of Preterm Infants, a Randomized Clinical Trial

BACKGROUND AND OBJECTIVES: Lower concentrations of oxygen (O2) (≤30%) are recommended for preterm resuscitation to avoid oxidative injury and cerebral ischemia. Effects on long-term outcomes are uncertain. We aimed to determine the effects of using room air (RA) or 100% O2 on the combined risk of death and disability at 2 years in infants <32 weeks’ gestation. METHODS: A randomized, unmasked study designed to determine major disability and death at 2 years in infants <32 weeks’ gestation after delivery room resuscitation was initiated with either RA or 100% O2 and which were adjusted to target pulse oximetry of 65% to 95% at 5 minutes and 85% to 95% until NICU admission. RESULTS: Of 6291 eligible patients, 292 were recruited and 287 (mean gestation: 28.9 weeks) were included in the analysis (RA: n = 144; 100% O2: n = 143). Recruitment ceased in June 2014, per the recommendations of the Data and Safety Monitoring Committee owing to loss of equipoise for the use of 100% O2. In non-prespecified analyses, infants <28 weeks who received RA resuscitation had higher hospital mortality (RA: 10 of 46 [22%]; than those given 100% O2: 3 of 54 [6%]; risk ratio: 3.9 [95% confidence interval: 1.1–13.4]; P = .01). Respiratory failure was the most common cause of death (n = 13). CONCLUSIONS: Using RA to initiate resuscitation was associated with an increased risk of death in infants <28 weeks’ gestation. This study was not a prespecified analysis, and it was underpowered to address this post hoc hypothesis reliably. Additional data are needed.

Neurodevelopmental outcomes of extremely premature infants conceived after assisted conception: a population based cohort study

Objective To compare neurodevelopmental outcomes of extremely preterm infants conceived after assisted conception (AC) compared with infants conceived spontaneously (non-AC). Design Population-based retrospective cohort study. Setting Geographically defined area in New South Wales and the Australian Capital Territory, Australia served by a network of 10 neonatal intensive care units. Patients Infants <29 weeks’ gestation born between 1998 and 2004. Intervention At 2–3 years corrected age, 1473 children were assessed with either the Griffiths Mental Developmental Scales or the Bayley Scales of Infant Development. Main outcome measure Moderate/severe functional disability defined as developmental delay (Griffiths General Quotient or Bayley Mental Developmental Index >2 SD below the mean), cerebral palsy (unable to walk without aids), deafness (bilateral hearing aids or cochlear implant) or blindness (visual acuity <6/60 in the better eye). Results Mortality and age at follow-up were comparable between the AC and non-AC groups. Developmental outcome was evaluated in 217 (86.5%) AC and 1256 (71.7%) non-AC infants. Using multivariate adjusted analysis, infants born after in-vitro fertilisation at 22–26 weeks’ gestation (adjusted OR 1.79, 95% CI 1.05 to 3.05, p=0.03) but not at 27–28 weeks’ gestation (adjusted OR 0.81, 95% CI 0.37 to 1.77; p=0.59) had higher rate of functional disability than those born after spontaneous conception. Conclusions AC is associated with adverse neurodevelopmental outcome among high risk infants born at 22–26 weeks’ gestation. This finding warrants additional exploration.

Galvanised by a respiratory distress diagnosis

The third pregnancy of a 38-year old Caucasian G3P2 woman had been unremarkable apart from pregnancy-induced cholestasis and group B streptococcus (GBS) detected on a routine 35-week high vaginal swab and for which intrapartum penicillin was administered. Following induction of labour at 38 weeks’ gestation for worsening cholestasis, the woman proceeded to a normal vaginal delivery of a live male infant. There was no maternal pyrexia and the liquor was clear. The parents were non-consanguineous and neither the parents nor the other siblings had a history of pulmonary disease. The baby was born with Apgar scores of 8 and 9 at 1 and 5 min, respectively. He developed respiratory distress almost immediately, with an audible grunt, flaring of the alae nasi and tachypnoea. Oxyhaemoglobin saturation (SpO2) was 82% when breathing room air so the infant was placed in a head box (HB) with fractional inspired oxygen (FiO2) of 40% to maintain SpO2 >95%. A chest x ray (CXR) showed a coarse reticular-granular pattern appearance, fluid in the right horizontal fissure and low lung volume. Blood cultures were collected and empirical antibiotics (amoxycillin and gentamicin) were started. Capillary blood gas analysis at this stage showed: pH 7.26, pCO2 61, pO2 32, BE 0.7. Over the next 3 h, oxygen requirement decreased to FiO2 32%, but the infant remained tachypnoeic. The NICU registrar thought the respiratory distress was probably due to transient tachypnoea of the newborn (TTN) or congenital pneumonia.

Antenatal gastrointestinal anomalies in neonates subsequently found to have alveolar capillary dysplasia

Alveolar capillary dysplasia (ACD) is a rare condition with variable presentation and clinical course. Clinicians should consider this diagnosis in neonates presenting with nonlethal congenital gastrointestinal malformation, a period of well‐being after birth then unremitting hypoxemia and refractory pulmonary hypertension. Lung biopsy and FOXF1 gene testing may help in diagnosis.

Expression of Kappa Opioid Receptors in Developing Rat Brain –Implications for Perinatal Buprenorphine Exposure

Buprenorphine, a mu opioid receptor partial agonist and kappa opioid receptor (KOR) antagonist, is an emerging therapeutic agent for maternal opioid dependence in pregnancy and neonatal abstinence syndrome. However, the endogenous opioid system plays a critical role in modulating neurodevelopment and perinatal buprenorphine exposure may detrimentally influence this. To identify aspects of neurodevelopment vulnerable to perinatal buprenorphine exposure, we defined KOR protein expression and its cellular associations in normal rat brain from embryonic day 16 to postnatal day 23 with double-labelling immunohistochemistry. KOR was expressed on neural stem and progenitor cells (NSPCs), choroid plexus epithelium, subpopulations of cortical neurones and oligodendrocytes, and NSPCs and subpopulations of neurones in postnatal hippocampus. These distinct patterns of KOR expression suggest several pathways vulnerable to perinatal buprenorphine exposure, including proliferation, neurogenesis and neurotransmission. We thus suggest the cautious use of buprenorphine in both mothers and infants until its impact on neurodevelopment is better defined.

Retrospective study found that outpatient care for infants exposed to drugs during pregnancy was sustainable and safe

We determined the safety, feasibility and sustainability of an outpatient model of care for infants exposed to intra‐uterine drugs.