How parents of premature infants gather information and obtain support.

PURPOSE: To identify the process by which parents of premature infants seek information, the kinds of information they seek, and the resources they use to meet their educational and support needs. DESIGN/SAMPLE: Descriptive study using 19 parent interviews and 64 questionnaires. MAIN OUTCOME VARIABLE; The process parents use to obtain information and support. RESULTS: Parents of premature infants make a transition from being passive recipients of information to actively seeking it. They spend 10-20 hours a week gathering information during the first month of the baby's hospitalization. They desire more information than is provided, particularly in the areas of infant health, infant care, and coping. Family is the primary source of support prior to birth and after discharge, but during the infant's convalescence, nurses are the main source of support and help for parents in understanding and adapting to their baby. Many parents would use a computer-based resource for information if it were available to them.

Risk for later school problems in preterm children who do not cooperate for preschool developmental testing.

OBJECTIVE: To determine whether preterm children born at

Motor organization in very low birth weight infants during caregiving: effects of a developmental intervention.

The purpose of this study was to determine whether an individualized approach to handling very low birth weight (VLBW) infants designed to support development would result in less motor disorganization than the task-oriented approach in traditional use. Using a quasi-experimental crossover design, motor responses were investigated in 38 infants (< or = 1700 g, 53% male, 89% white) observed at 28, 32, and 36 weeks post-conceptional age. Subjects served as their own controls. Motor responses were coded from direct observation and videotapes. Results demonstrated that during developmental handling, (1) the overall amount of movement was less, the number of organized movements was greater, and the number of disorganized movements was less than during traditional handling; and (2) the amount of movement increased over time, but in the traditional condition, it peaked at 32 weeks. Results support positive effects of developmental handling and suggest the potential for reducing the prevalence of minor motor impairments in VLBW infants.

Developmental outcome of very low birth weight infants at four years of age as a function of biological risk and psychosocial risk.

The continuing contribution of early biological and psychosocial risk factors to developmental outcome of 55 very low birth weight infants (< or = 1500 g) was assessed at 4 years of age. Biological risk, assessed by the Neurobiologic Risk Score, accounted for significant portions of the variance in the perceptual-performance (17%) and motor (35%) dimensions of the McCarthy Scales of Children's Abilities. Psychosocial risk, reflected in maternal appraisals of daily stress during the newborn period, did not account for a significant portion of variance in any of the McCarthy Scales. Maternal education level, however, another measure of psychosocial risk, accounted for significant portions of variance (from 6% to 34%) on each of the McCarthy Scales. Movement from low neurobiologic risk status to poor outcome status at 4 years of age was associated with a number of psychosocial variables, including maternal education and early levels of maternal daily stress. The findings are discussed in terms of early markers for very low birth weight infants who require careful follow-up and of potential intervention targets to promote developmental outcome.

Behavioral characteristics of very-low-birth-weight infants of varying biologic risk at 6, 15, and 24 months of age.

OBJECTIVE: To explore the relationship between developmental outcome and behavior of very-low-birth-weight (VLBW) infants (< or = 1500 g) at high and low biologic risk. DESIGN: Descriptive, ex post facto. SETTING: Clinic for follow-up of infants at high risk. PARTICIPANTS: A convenience sample of 102 VLBW infants, free of major congenital anomalies, who completed 6-, 15-, and 24-month developmental testing and who were part of a larger study of 274 VLBW infants. MAIN OUTCOME MEASURE: Bayley Scales of Infant Development. RESULTS: Infants at high biologic risk, versus infants at low biologic risk, were less attentive and active through age 15 months and were less adept in gross and fine motor skills through age 24 months (p < or = 0.05-0.001). Infants with continuous delay were less attentive than infants with no delay or late delay through age 24 months, less active through age 15 months (p < or = 0.001-0.001), and less skilled in motor behaviors through age 24 months (p < or = 0.05-0.001). CONCLUSION: Infants at high biologic risk and infants with developmental delays are less attentive, less active, and less skilled in motor tasks during the first 15-24 months of life, suggesting an association between biologic risk and behavior and developmental delay and behavior.

Influence of acidosis, hypoxemia, and hypotension on neurodevelopmental outcome in very low birth weight infants.

OBJECTIVE: We previously demonstrated that acidosis (pH < 7.15) predicts poor motor outcome in very low birth weight (VLBW) infants. The present study was undertaken to examine the association between acidosis and developmental outcome in more detail and to better understand the interrelationship of acidosis with related factors such as hypoxemia and hypotension. METHODS: The nursery records of 191 infants enrolled in our VLBW follow-up study were reviewed to identify the type of acidosis (metabolic or respiratory) present, measure the duration of single and cumulative episodes, and examine the interaction of acidosis with hypoxemia and hypotension. The Bayley Scales of Infant Development and a detailed neurologic examination were performed at 6 (n = 158) and 24 (n = 106) months corrected age. RESULTS: At 6 months, both respiratory and metabolic acidosis as well as the total duration and longest single episode of acidosis were significantly correlated with cognitive, motor, and neurologic outcome (P < .0001). By 24 months, only the association of the metabolic component of acidosis with all three outcome measures remained significant. Duration of hypotension independently correlated with outcome at both testing periods (P < .002) but isolated hypoxemia did not. The metabolic component of acidosis and isolated hypotension contributed significantly to the variance in all three outcome measures (P < .05). Duration of hypoxemia, but not hypotension, contributed significantly (53%) to the variance in the metabolic component of acidosis. CONCLUSION: We conclude that it is the metabolic component of acidosis that is important in predicting poor developmental outcome in VLBW infants. The detrimental effect of hypoxemia appears to be closely related to the occurrence of metabolic acidosis while hypotension has an independent effect on outcome.

Developmental outcome of very low birth weight infants as a function of biological risk and psychosocial risk.

The relative contribution of biological and psychosocial risk factors to developmental outcome of 102 very low birth weight infants (< 1500 g) was delineated through 24 months corrected age. Biological risk, assessed by the Neurobiologic Risk Score (NBRS), accounted for significant amounts of variance in Bayley Mental Developmental Index (MDI) and Psychomotor Developmental Index (PDI) at the 6-, 15-, and 24-month assessment points. Psychosocial risk, reflected in maternal appraisals of daily stress, accounted for a significant increment in cognitive outcome (MDI), over and above that accounted for by the NBRS, at each assessment point. Cognitive functioning at each assessment point differed as a function of biological risk and psychosocial risk status. The findings are discussed in terms of maternal stress as a marker of, and salient intervention target for, caregiving environments that can maximize or minimize the effects of biological vulnerability.

Nursery neurobiologic risk score: levels of risk and relationships with nonmedical factors.

This study compares the Neurobiologic Risk Score (NBRS) with developmental outcome in 199 infants < or = 1500 g birth weight to determine levels of risk and to investigate the relative contributions of the NBRS and nonmedical factors to developmental outcome. The NBRS correlated significantly (p < .0001) with the Bayley Mental (MDI) and Psychomotor (PDI) Indexes, and neurologic examination score (NS) at 6, 15, and 24 months. Three risk groups were identified: low, NBRS < or = 4; intermediate, NBRS 5 to 7; and high, NBRS > or = 8 with an incidence of major handicaps at 24 months of 7%, 32%, and 50%, respectively. Of eight factors considered, the NBRS accounted for the greatest variance: MDI, 14 to 27%; PDI, 25 to 29%; NS, 34 to 42%. Additional increments of variance were contributed by gender (MDI, PDI, NS), maternal intelligence and race (MDI), and maternal education (PDI). The NBRS is a useful tool for identifying risk for developmental abnormalities due to neonatal medical events.

Do primary care physicians prefer dictated or computer-generated discharge summaries?

OBJECTIVE: To determine the preference of primary care physicians for computer-generated vs dictated discharge summaries from a neonatal intensive care unit. DESIGN: Survey mailed to primary care physicians. SETTING: Regional referral area of a level III neonatal intensive care unit. PARTICIPANTS: Pediatricians and family medicine physicians caring for infants discharged from the neonatal intensive care unit. RESULTS: Of 58 questionnaires sent, 45 (78%) were returned. Overall, 33 physicians (73%) either strongly or mildly preferred the computer-generated discharge summary; eight (18%) had no preference; and four (9%) preferred the dictated discharge summary (P < .001). The category of strongest preference was relevance of information for continued patient care. Preference for type of discharge summary was not significantly influenced by time in practice, type of practice, preference to read or scan summaries, or frequency of computer use. CONCLUSION: Primary care physicians prefer computed-generated discharge summaries to dictated discharge summaries.

Narcotic sedation stabilizes arterial blood pressure fluctuations in sick premature infants.

Blood pressure (BP) fluctuations in infants with respiratory distress syndrome (RDS) are related to spontaneous respirations and have been associated with an increased incidence of intraventricular hemorrhage. Both initiation of mechanical ventilation in the nonventilated infant and muscle paralysis in the ventilated infant can help stabilize these fluctuations. We hypothesized that narcotic sedation would also be effective in decreasing BP fluctuations when pharmacologic intervention is deemed necessary. Twenty premature infants were paralyzed with pancuronium or sedated with morphine or fentanyl for clinical indications. Blood pressure and respiratory tracings before and after medication were analyzed for average peak systolic BP (SBP) and the percentage of spontaneous respirations (SResp). Fluctuations of SBP were quantitated using the coefficient of variation (CV). A marked reduction was found in both CV and SResp following administration of all three drugs. Peak inspiratory pressure and ventilator rate were increased in the pancuronium group. In 7 out of 14 patients in whom spontaneous respirations persisted following sedation, there was a strong association between the percentage of decrease in CV and SResp. Advantages of narcotic sedation over muscle paralysis are discussed.

Cerebral oxygen monitoring with near infrared spectroscopy: clinical application to neonates.

Near infrared spectroscopy is a new noninvasive optical method for bedside monitoring of cerebral oxygenation. It uses differential absorbance of near infrared light to assess relative changes in the oxidation-reduction state of cytochrome aa3, as well as changes in the amounts of oxyhemoglobin, deoxyhemoglobin, and blood volume in the monitored field. Although this technique is applicable to all ages and sizes of patients and to multiple clinical settings, the majority of clinical studies to date have focused on the neonate. These studies have demonstrated its potential for advancing neonatal care and in understanding how diseases and therapies affect cerebral oxygenation. This paper reviews the near infrared spectroscopy technique and summarizes its potential applications in the field of neonatal intensive care.

Near-infrared spectroscopy.

Near-infrared spectroscopy is a new technique for noninvasive monitoring of tissue oxygenation and hemodynamics. Until now, it has been used solely for research into the physiopathology of the brain. This technique offers considerable untapped potential for research and clinical applications.

Nursery Neurobiologic Risk Score: important factor in predicting outcome in very low birth weight infants.

We developed a nursery Neurobiologic Risk Score (NBRS) based on potential mechanisms of brain cell injury in preterm infants and correlated it with developmental outcome at the corrected ages of 6, 15, and 24 months. The NBRS was determined at 2 weeks of age and at the time of discharge from intensive care in 58 preterm infants with birth weights less than or equal to 1500 gm. The NBRS correlated significantly with the Bayley Scales of Infant Development, Mental Development Index (MDI) (r = -0.61 to -0.40) and Psychomotor Development Index (PDI) (r = -0.59 to -0.46), and with abnormal neurologic examination findings (r = 0.59 to 0.73) at the three testing periods. Although 12 of the 13 items composing the NBRS individually correlated with one or more outcome variables, seven items (infection, blood pH, seizures, intraventricular hemorrhage, assisted ventilation, periventricular leukomalacia, and hypoglycemia) accounted for almost all of the explained variance. Logistic regression of individual items demonstrated intraventricular hemorrhage to be the most important item for predicting the MDI at 24 months; pH was the most influential item for predicting the PDI at every testing period. A shorter, revised NBRS that included only the seven significant items demonstrated as strong a correlation with developmental outcome as the original NBRS. A revised 2-week score of greater than or equal to 5 or a discharge score of greater than or equal to 6 demonstrated 100% specificity and had a 100% positive predictive value for an abnormal outcome at 24 months of age in this group of infants. We conclude that the NBRS identifies during the intensive care nursery stay those infants at highest risk for an abnormal outcome related to nursery events. In addition, analysis of NBRS items provides insight into the relative importance of individual factors for influencing mental, motor, and neurologic outcome.

Fluctuations of arterial blood pressure decrease with mechanical ventilation in premature infants with respiratory distress syndrome.

Marked fluctuations of arterial blood pressure (ABP) are associated with an increased risk of intraventricular hemorrhage. The pathophysiology is linked to spontaneous breathing. We hypothesized that these fluctuations would decrease after initiation of effective mechanical ventilation. We studied 20 infants treated with nasal continuous positive airway pressure (CPAP) and oxygen for early respiratory distress. Eleven required intubation for clinical indications. Simultaneous ABP and respiratory tracing obtained before and following intubation were analyzed for average peak systolic blood pressure (SBP) and the percentage of spontaneous respirations (SResp). Fluctuations of SBP were quantitated using the coefficient of variation (CV). The remaining 9 infants with minimal lung disease served as a control group. There was a small increase in SBP, and a marked decrease in both CV and SResp following intubation. A significant correlation was found between the percent decreases in CV and SResp. We conclude that beat-to-beat fluctuations of ABP decrease after the initiation of effective mechanical ventilation. This effect is primarily due to a decrease in spontaneous breathing.

Cytomegalovirus infection in a neonatal intensive care unit. Subsequent morbidity and mortality of seropositive infants.

In a study of blood transfusion and cytomegalovirus (CMV) infection in 385 infants, 5 (8%) of 60 seropositive infants with birthweights less than or equal to 1250 g acquired CMV. Four infants had become seronegative by the time of viral excretion and demonstrated significant morbidity with one death. Morbidity included variant (atypical) lymphocytosis, thrombocytopenia, Staphylococcal epidermidis and Candida parapsilosis infections, and respiratory deterioration. Interestingly, the infant who exhibited only minimal morbidity was seropositive at the time of viral excretion. CMV seropositivity at birth may not protect low birthweight (LBW) infants from the morbidity and mortality associated with CMV infection.

Air embolism with survival in a neonate.

Air embolism in neonates is usually fatal. We describe an infant who survived and discuss the pathogenesis and management of this condition.

Congenital apnea with medullary and olivary hypoplasia: a pathologic study with computer reconstructions.

We report a three-month-old infant with congenital central apnea who was ventilator-dependent throughout his brief life. At autopsy the most significant findings were localized to the medulla and included severe tegmental necrosis involving respiratory-related sites and olivary hypoplasia. Golgi impregnations of the cerebellum demonstrated several Purkinje cells with changes consistent with experimental olivary ablation. The majority of Purkinje cells, however, were normal; this observation suggests that in an early and subtotal olivary lesion, the incomplete complement of olivary neurons maintains sufficient collateral axonal branches to compensate for decreased cell number. Computer graphics enabled us to dissect the components of the complex medullary pathology and examine them individually and in selected combinations in three dimensions. Computer reconstruction aided the identification and dating of a malformative lesion (first trimester) from a later (second/third trimester), superimposed destructive lesion. This report suggests that the synthesis of complex morphologic data in human neuropathology into meaningful three-dimensional visual displays by computer reconstruction facilitates their comprehension. Computer reconstruction is especially valuable in the elucidation of 3-D topographic relationships in functionally and architecturally complex regions such as the brain stem.