Robert E. Piecuch

Patent ductus arteriosus and its treatment as risk factors for neonatal and neurodevelopmental morbidity.

OBJECTIVES. The purpose of this work was to determine whether the reported association between neonatal morbidities and a patent ductus arteriosus is because of the left-to-right patent ductus arteriosus shunt itself, the therapies used to treat it, or the immaturity of the infants who are likely to develop a patent ductus arteriosus. METHODS. A total of 446 infants (<28 weeks gestation) were treated with the same patent ductus arteriosus care–oriented protocol, and logistic regression analysis was used to examine the effects of several patent ductus arteriosus–related variables (presence of a symptomatic patent ductus arteriosus, the number of indomethacin doses used, the ductus response to indomethacin, and the use of surgical ligation) on the incidence of retinopathy of prematurity, necrotizing enterocolitis, chronic lung disease, death, and neurodevelopmental impairment. RESULTS. Most of the predictive effects that the presence of a patent ductus arteriosus and its treatment had on neonatal morbidity could be accounted for by the infants immature gestation. Use of surgical ligation, however, was significantly associated with the development of chronic lung disease and was independent of immature gestation, other patent ductus arteriosus–related variables, or other perinatal and neonatal risk factors known to be associated with chronic lung disease. CONCLUSIONS. These findings add to the growing uncertainty about the benefits and risks of surgical ligation during the neonatal period.

Outcome of infants born at 24–26 weeks' gestation: II. Neurodevelopmental outcome

Objective To assess the neurodevelopmental outcome of infants born at 24–26 weeks gestation. Methods One hundred thirty-eight nonanomalous infants were born at our hospital after pregnancies of 24–26 weeks gestation between 1990 and 1994. Ninety-four infants survived to discharge and 86 were followed in a nursery follow-up program for outcome. Associations between gestational age and neurodevelopmental outcome and risk factors and outcome were analyzed. Mean age at follow-up was 32 months. Results The frequency of cerebral palsy did not differ significantly in the three groups (11, 20, and 11% at 24, 25, and 26 weeks, respectively). The incidence of normal cognitive outcome was associated significantly with gestational age at birth (28, 47, and 71% normal at 24, 25, and 26 weeks, respectively). Poor neurologic outcome was associated with the medical risk factor of intracranial hemorrhage grade 3 or 4 or periventricular leukomalacia. Poor cognitive outcome was correlated with both medical and social risk factors; however, there was an association between poor cognitive outcome and lower gestational age (P <.05), regardless of the relationships of any other risk factors to cognitive outcome. Conclusion Although the incidence of cerebral palsy was low in these three groups, the high percentage of infants born at 24 and 25 weeks gestation with cognitive deficits is concerning.

Quality-of-Care Indicators for the Neurodevelopmental Follow-up of Very Low Birth Weight Children: Results of an Expert Panel Process

OBJECTIVE. To develop a set of quality indicators for the neurodevelopmental follow-up care of very low birth weight (VLBW; <1500 g) children. METHODS. We reviewed the scientific literature on predictors of neurodevelopmental outcomes for VLBW children and the clinical practice guidelines relevant to their care after hospital discharge. An expert panel with members nominated by the American Academy of Pediatrics, the National Institute of Child Health and Human Development, the Vermont Oxford Network, and the California Childrens Service was convened. We used a modified Delphi method to evaluate and select the quality-of-care indicators. RESULTS. The panel recommended a total of 70 indicators in 5 postdischarge follow-up areas: general care; physical health; vision, hearing, speech, and language; developmental and behavioral assessment; and psychosocial issues. Of these, 58 (83%) indicators were in preventive care, 5 (7%) were in acute care, and 7 (10%) were in chronic care. CONCLUSION. The quality indicators cover follow-up care for VLBW infants with various medical conditions. Given the elevated rates of long-term neurodevelopmental disabilities and the potential impact of poor health care, this new set of indicators provides an opportunity to assess and monitor the quality of follow-up care with the ultimate aim of improving the quality of care for this high-risk population.

Cerebellar Hemorrhage on Magnetic Resonance Imaging in Preterm Newborns Associated with Abnormal Neurologic Outcome

OBJECTIVEnTo investigate the relationship between cerebellar hemorrhage in preterm infants seen on magnetic resonance imaging (MRI), but not on ultrasonography, and neurodevelopmental outcome.nnnSTUDY DESIGNnImages from a cohort study of MRI in preterm newborns were reviewed for cerebellar hemorrhage. The children were assessed at a mean age of 4.8 years with neurologic examination and developmental testing using the Wechsler Preschool and Primary Scale of Intelligence, Third Edition.nnnRESULTSnCerebellar hemorrhage was detected on both ultrasonography and MRI in 3 of the 131 preterm newborns evaluated, whereas smaller hemorrhages were seen only on MRI in 10 newborns (total incidence, 10%). Adjusting for gestational age at birth, intraventricular hemorrhage, and white matter injury, cerebellar hemorrhage detectable solely by MRI was associated with a 5-fold increased odds of abnormal neurologic examination compared with newborns without cerebellar hemorrhage (outcome data in 74%). No association with the Wechsler Preschool and Primary Scale of Intelligence, Third Edition score was found.nnnCONCLUSIONSnCerebellar hemorrhage is not uncommon in preterm newborns. Although associated with neurologic abnormalities, hemorrhage seen only on MRI is associated with much more optimistic outcomes than that visible on ultrasonography.

Outcome of infants born at 24-26 weeks' gestation : I. Survival and cost

Objective To determine neonatal survival, short-term morbidities, and cost per survivor in pregnancies delivered at 24–26 weeks gestation in a center in which antenatal steroids and exogenous surfactant are standard care. Methods A retrospective cohort study compared survival, short-term outcome, and initial hospital charges for pregnancies delivered at 24–26 weeks during 1990–1994. We calculated hospital costs for each year by using the corresponding institutional cost-charge ratio. Results There were 138 infants after excluding those with severe anomalies. Survival was 43%, 74%, and 83% at 24, 25, and 26 weeks, respectively (P = .006). The majority of women received antenatal steroids, and the majority of surviving neonates received exogenous surfactant. Severe retinopathy of prematurity and chronic lung disease decreased significantly from 24 to 26 weeks (P ≤ .026). The likelihood of having a surviving infant without chronic lung disease or severe retinopathy of prematurity was 35% at 24 weeks and 78% at 26 weeks. Hospital costs for the 29 nonsurvivors were

Effect of medical and social risk factors on outcome of prematurity and very low birth weight

1.46 million and for the 94 surviving infants were

Visual Acuity Development in Normal and Abnormal Preterm Human Infants

16.9 million. The cost per day was similar at each gestational age, whereas the cost to produce a survivor was

Neurodevelopmental outcomes following two different treatment approaches (early ligation and selective ligation) for patent ductus arteriosus.

294,749,

School Age Outcome in Low Birth Weight Preterm Infants

181,062, and

Selected Indications for and Applications of Magnetic Resonance Angiography in Children

166,215 at 24, 25, and 26 weeks, respectively. Conclusion Survival at 24 weeks was only 43% despite treatment with antenatal steroids and exogenous surfactant. The cost per survivor for infants born at 24 weeks was higher than the cost for those born after 1 more week in utero. Outcome improved markedly between 24 and 26 weeks, and small differences in gestational age lead to large economic differences. All efforts should be attempted to prolong pregnancy, and if prolongation is unsuccessful, treatment options including nonintervention should be available to parents of 24-week gestations.