Shobhana A. Desai

Clinical Antecedents of Neurologic and Audiologic Abnormalities in Survivors of Neonatal Extracorporeal Membrane Oxygenation

Extracorporeal membrane oxygenation is an effective rescue treatment for severe cardiorespiratory failure in term or near-term neonates, although cerebral palsy, mental retardation, and sensorineural hearing loss are observed in 10 to 20% of survivors. The objective of the present study was to identify potential risk factors that may explain the neurologic and audiologic sequelae noted in 19% of 181 survivors of neonatal extracorporeal membrane oxygenation from our hospital. Our results suggest the following findings in survivors of severe cardiorespiratory failure treated with neonatal extracorporeal membrane oxygenation: (1) hypotension or the need for cardiopulmonary resuscitation before extracorporeal membrane oxygenation significantly increases the risk of spastic cerebral palsy, (2) profound hypocarbia before extracorporeal membrane oxygenation is associated with a significantly increased risk of hearing loss, (3) mental retardation in the absence of spastic cerebral palsy is unexplained except when due to abnormal fetal brain development, and (4) hypoxemia in the absence of hypotension does not increase the risk of neurologic or audiologic sequelae. (J Child Neurol 1997;12:415-422).

Cranial ultrasound and clinical studies in preterm infants.

Serial ultrasound imaging of the brain was used to determine the ventricular index (VI), and the ratio (VR) of the VI to the cranial hemidiameter during the nursery course and first year post-term in preterm infants of less than 33 weeks gestation. Twenty-nine of the infant survivors with no intracranial hemorrhage or major medical complication during their nursery course composed group 1. Twenty-two survivors with intracranial hemorrhage unassociated with early ventricular dilation composed group 2. Group 3 was comprised of 10 other survivors who had neonatal intraventricular hemorrhage with early ventriculomegaly; all 10 infants had at least one major medical complication during their neonatal course. In groups 1 and 2 the VR decreased and the VI increased significantly with age post-conception. Infants in group 3, compared with those in groups 1 or 2, had decreased occipitofrontal growth during the early postnatal period and increased VR and VI during the neonatal period and first year post-term. These results suggest that the ventriculomegaly associated with neonatal intracranial hemorrhage cannot be explained by posthemorrhagic hydrocephalus alone and may also be related to cerebral atrophy or decreased brain growth or both. Neurodevelopmental assessments at 20 to 30 months of age disclosed significantly lower Bayley Motor Development scores in group 3 compared with groups 1 or 2. Four infants in group 3, but none in groups 1 or 2, had cerebral palsy. The neurodevelopmental deficits in group 3 infants may reflect the complex pathogenesis of the ventriculomegaly as well as the effects of the intraventricular hemorrhage and posthemorrhagic hydrocephalus.

Right common carotid artery reconstruction after extracorporeal membrane oxygenation : vascular imaging, cerebral circulation, electroencephalographic, and neurodevelopmental correlates to recovery

OBJECTIVE Right common carotid artery (RCCA) ligation after extracorporeal membrane oxygenation by venoarterial bypass may contribute to lateralized cerebral injury. Reconstruction of this artery after extracorporeal membrane oxygenation has proved feasible but has not been evaluated for neurologic outcome in any substantial series of infants. METHODS We evaluated RCCA reconstruction in 47 infants treated with ECMO and compared their cerebrovascular and neuroanatomic imaging findings, electroencephalograms, and developmental outcomes with those of 93 infants who had no reconstruction. SUMMARY RESULTS: Color Doppler blood flow imaging revealed that carotid artery patency was usually obtained after RCCA reconstruction. Right internal carotid and bilateral anterior and middle cerebral arterial blood flow velocities were generally higher, and were more symmetrically distributed in infants with reconstructed RCCA. Electroencephalography did not disclose an increased risk of deterioration or marked abnormalities in infants after reconstruction, nor were neuroimaging findings consistent with an increased number of either focal or generalized abnormalities. Neurodevelopmental follow-up revealed no differences in the incidence of delays between those with a reconstructed RCCA and those with a ligated RCCA during the first year of life. CONCLUSIONS Reconstruction of the RCCA after extracorporeal membrane oxygenation may facilitate normal distribution of cerebral blood flow through the circle of Willis, and may augment both left and right middle cerebral artery blood flow immediately after decannulation. The long-term consequences of either ligation or reconstruction of the RCCA will require careful scrutiny, however, before either course is recommended routinely.

Sensitivity and specificity of the neonatal brain-stem auditory evoked potential for hearing and language deficits in survivors of extracorporeal membrane oxygenation.

OBJECTIVE We determined the sensitivity and specificity of neonatal brain-stem auditory evoked potentials (BAEP) as markers for subsequent hearing impairment and for developmental problems found later in infancy and childhood. METHODS BAEP studies were performed before discharge in infants treated with extracorporeal membrane oxygenation (ECMO), and two specific abnormalities were analyzed: elevated threshold and delayed central auditory conduction. Behavioral audiometry was repeated during periodic follow-up until reliable responses were obtained for all frequencies, and standardized developmental testing was also conducted. The sensitivity and specificity of an elevated threshold on the neonatal BAEP for detecting subsequent hearing loss, and the relationship of any neonatal BAEP abnormality to language or developmental disorders in infancy, were calculated. RESULTS Test results for 46 ECMO-treated infants (57.5%) were normal, and those for 34 infants (42.5%) were abnormal, with either elevated wave V threshold, prolonged wave I-V interval, or both on neonatal BAEP recordings. Most significantly, 7 (58%) of the 12 children with subsequent sensorineural hearing loss had left the hospital after showing normal results on threshold tests. There was no significant difference in the frequency of hearing loss between subjects with abnormal (5/21, or 24%) and those with normal BAEP thresholds (7/59, or 12%; Fisher Exact Test, p = 0.28). Therefore the sensitivity of neonatal BAEP testing for predicting subsequent hearing loss was only 42%. Neonatal BAEP specificity for excluding subsequent hearing loss was 76%. In contrast, on language development testing, 19 children demonstrated receptive language delay. Of these children, 12 (63%) had abnormal neonatal BAEP recordings and 7 (37%) had a normal BAEP threshold, normal central auditory conduction test results, or both (p = 0.04). CONCLUSIONS Neonatal BAEP threshold recordings were of limited value for predicting subsequent hearing loss common in ECMO-treated survivors. However, an abnormal neonatal BAEP significantly increased the probability of finding a receptive language delay during early childhood, even in those with subsequently normal audiometry findings. Because neonatal ECMO is associated with a high risk of hearing and receptive language disorders, parents should be counseled that audiologic and developmental follow-up evaluations in surviving children are essential regardless of the results of neonatal BAEP testing.

Adverse neurodevelopmental outcome after extracorporeal membrane oxygenation among neonates with bronchopulmonary dysplasia.

OBJECTIVE The relationship between bronchopulmonary dysplasia (BPD) and neurodevelopmental outcome after extracorporeal membrane oxygenation (ECMO) has not been extensively reported. We compared the outcomes in a large series of infants with and without BPD after ECMO. STUDY DESIGN Hospital charts and follow-up records of 145 infants treated with ECMO (1985 through 1990) were reviewed. Complete long-term respiratory and follow-up outcome data were available in 64 infants. BPD occurred in 17 survivors; the remaining 47 did not have BPD. RESULTS Babies with BPD were more likely to have had respiratory distress syndrome. Mean (+/- SD) age at ECMO initiation was later for the BPD group (127+/-66 vs 53+/-39 hours, p < 0.001), and the duration of ECMO treatment was longer (192+/-68 vs 119+/-53 hours, p < 0.001). Bayley Scales of Infant Development scores at <30 months were lower in infants with BPD (p < 0.001), as were three of four Mullen Scales of Early Learning scores (> or = 30 months, p < 0.001 or p = 0.01). At 57+/-16 months 11 (64%) patients with BPD had mild neurologic disabilities, and 3 (18%) had severe disabilities. At a similar age (53+/-16 months, p = NS) 16 (34%) patients without BPD had mild disabilities, whereas 2 (4%) had severe disabilities (p < 0.01). CONCLUSIONS The occurrence of BPD after ECMO is associated with adverse neurodevelopmental outcome. Patients with BPD after ECMO merit close long-term follow-up.

Neonatal electroencephalogram does not predict cognitive and academic achievement scores at early school age in survivors of neonatal extracorporeal membrane oxygenation.

Extracorporeal membrane oxygenation is an effective rescue treatment for severe cardiorespiratory failure in term or near-term neonates, although a wide range of neurologic sequelae have been noted in a substantial minority of survivors. The objective of the present study was to determine the value of the neonatal electroencephalogram (EEG) for predicting Wechler Preschool and Primary Scale of Intelligence-Revised (WPPSI-R), Wide Range Achievement Test, and Wide Range Assessment of Memory and Language scores at early school age in 66 testable survivors of extracorporeal membrane oxygenation who were not severely brain damaged. Technically satisfactory EEG recordings were obtained at least twice following admission to our nursery and prior to discharge. The EEGs were classified and graded according to standard criteria. The developmental test results of those who had only normal or mildly abnormal neonatal EEGs (group 1, n = 9) were compared with those who had at least one moderately or markedly abnormal recording (group 2, n = 57). School-age test and subtest scores were not statistically significantly worse in group 2 versus group 1 infants. No child in group 1 and five children in group 2 had WPPSI-R Full-Scale IQ scores of less than 70. Of the nine children in group 2 who had at least one markedly abnormal neonatal EEG recording (graded as burst suppression or as electrographic seizure), only two had abnormally low WPPSI-R Full-Scale IQ scores. We conclude that EEG recordings obtained during the neonatal course of neonates treated with extracorporeal membrane oxygenation do not predict cognitive and academic achievement test results in survivors at early school age who were testable and not severely brain damaged. (J Child Neurol 2001;16:745-750).

PRIMARY DIAGNOSES AS PREDICTORS OF LONG-TERM DEVELOPMENTAL OUTCOME IN SCHOOL AGE SURVIVORS OF EXTRACORPOREAL LIFE SUPPORT (ECLS): A LONGITUDINAL STUDY. ▴ 1581

PRIMARY DIAGNOSES AS PREDICTORS OF LONG-TERM DEVELOPMENTAL OUTCOME IN SCHOOL AGE SURVIVORS OF EXTRACORPOREAL LIFE SUPPORT (ECLS): A LONGITUDINAL STUDY. ▴ 1581

Retinopathy of prematurity: Does race matter?

Objective: Severe Retinopathy of Prematurity (ROP) is a primary cause of visual morbidity for very low birth weight infants. Known risk factors include short gestational age, low birth weight and supplemental oxygen exposure. Some studies have shown that Black infants are less at risk for severe ROP than White infants, however this finding has not been confirmed in studies designed to look at the risk of ROP and race/ethnicity specifically. The purpose of this study is to assess the relationship between the race/ethnicity of infants and the risk of severe ROP for a sample of 1,604 infants in 1,189 hospitals located in 39 states. Patients and methods: ParadigmHealth database records for surviving infants born between 1/1/2001 and 12/31/2004 with a birth weight less than or equal to 1250 g were included in this analysis (n = 1,604). Multivariate logistic regression was used to assess the association between race/ethnicity and risk for severe ROP. Models were adjusted for birth weight, gestational age, Apgar score, race and measures of illness severity including days on oxygen and mechanical ventilation, sepsis, intraventricular hemorrhage, patent ductus arteriosus, necrotizing enterocolitis and pneumothorax. Results: In the analytic data set, the distribution of maternal race was 47.2% White, 35.3% Black, 14.9% Hispanic and 3.2% Asian. Of these infants, 9.4% developed severe ROP; 6.6% for Blacks, 9.6% for Whites, 13.8% for Hispanics and 15.7% Asians. Compared to Black neonates, the unadjusted odds ratio for ROP among White infants was 1.5 (95% CI: 1.0, 2.3), for Hispanics 2.2 (95% CI: 1.4, 3.7) and for Asians 2.6 (95% CI: 1.2, 5.9). After adjustment for gestational age, birth weight and 1 minute Apgar score, the odds ratios increased to 2.0 (CI: 1.2, 3.2) for Whites, 2.7 (CI: 1.5, 4.8) for Hispanics and 5.3 (CI 1.9, 15.1) for Asians compared to Black neonates. Adjusting for additional markers of illness severity did not alter these results. Conclusions: Results revealed lower rates of ROP among Black confirming findings from earlier studies. Interestingly, relatively high rates of ROP were also found among Hispanic and Asian neonates compared to Black infants. Controlling for possibly confounding morbidities and measures of illness severity did not alter these results. Further research in this area is warranted.

The Efficacy of Paregoric Versus Tincture of Opium in the Treatment of Neonatal Abstinance Syndrome (NAS)

The Efficacy of Paregoric Versus Tincture of Opium in the Treatment of Neonatal Abstinance Syndrome (NAS)

OUTCOMES IN A LARGE POPULATION OF INFANTS FOLLOWING VENOVENOUS COMPARED TO VENOARTERIAL EXTRACORPOREAL LIFE SUPPORT (ECLS). |[utrif]| 1689

OUTCOMES IN A LARGE POPULATION OF INFANTS FOLLOWING VENOVENOUS COMPARED TO VENOARTERIAL EXTRACORPOREAL LIFE SUPPORT (ECLS). ▴ 1689