Components of Metabolic Syndrome at 22 years of Age - Findings From Pune Low Birth Weight Study.

BACKGROUND: To study the early markers of Metabolic syndrome in a cohort of low birth weight (LBW) children followed up since birth, at the age of 22 years. DESIGN: Prospective cohort study. SETTING: Tertiary-care hospital. PARTICIPANTS: Neonates weighing less than 2000 g discharged from a neonatal special care unit were followed up prospectively; 153 cases and 77 controls were assessed at 22 years of age. METHODS: Fasting, 30 minute and 120 minute glucose and insulin after a bolus of 75g of glucose was determined. Insulin resistance was calculated. A lipid profile was also done. Anthropometric measurements were taken and abdominal fat was determined by magnetic resonance imaging. MAIN OUTCOME: Prevalence of the five components of Metabolic Syndrome as described by the International Diabetic Federation (IDF). RESULTS: 65.1% of the cohort was born small for gestational age. All three components of Metabolic syndrome were present in only three cases and none of the controls. However, two components were present in 25 (16.4%) cases and 5 (6%) controls (P=0.039). Cases in the lowest quartile of birthweight who became big at 22 years had significantly higher fasting insulin (P=0.001), Homeostatic Model Assessment - Insulin Resistance (Homa-IR) (P=0.001) and higher systolic blood pressure. Sum of skinfold thickness at 4 sites correlated significantly with fasting insulin and HOMA-IR, and was a stronger correlate compared to BMI, waist circumference and MRI fat. There was no difference in the biochemical parameters between appropriate for gestational age and small for gestational age infants. CONCLUSION: Prevelence of three or more components of Metabolic syndrome was low in LBW children at 22 years, but of two components was high. Those 'Small at birth and big at 22 years' had high insulin resistance.

Pune low birth weight study - birth to adulthood - cognitive development.

OBJECTIVE: To assess the cognitive development of non-handicapped low birth weight (LBW) infants at 18 years. DESIGN: Prospective cohort study. SETTING: Infants born between 1987 - 1989 with birth weight less than 2000 g and discharged from a neonatal special care unit were followed up till the age of 18 years. METHODS: The intelligence quotient (IQ) was determined by Ravens progressive matrices. Assessment of adjustment and aptitude was done. RESULTS: The cohort of 161 LBW infants was divided into three groups according to their gestation - preterm SGA (n=61), full term SGA (n=30) and preterm AGA (n=70). 71 full term AGA infants served as controls. The IQ of the study group (Percentile 39.3) was significantly lower than that of controls (Percentile 54.9) (P=0.002). Preterm SGA subjects had the lowest IQ (Percentile 35.5), though just within normal limits. Males from the study group had significantly lower IQ than male controls (P=0.03). The IQ of PTSGA subjects of college educated mothers (P=0.004) and belonging to higher socio-economic class (P=0.04) was significantly higher. On the differential aptitude test, PTSGA subjects were poor in speed and mechanical reasoning. The 18 year IQ could be best predicted by IQ at 6 and 12 years. CONCLUSION: Preterm SGA children have the lowest IQ at 18 years, males have lower IQ. Maternal education and socio-economic status have great impact on cognitive development. Good prediction of the 18 year IQ can be done by the 6 and 12 year IQ.

Mortality and morbidity in extremely low birth weight (ELBW) infants in a neonatal intensive care unit.

OBJECTIVE: To determine the morbidity and mortality in ELBW babies till discharge from a Neonatal Intensive Care Unit (NICU). METHODS: This study was a prospective observational study conducted in a 40 bed well equipped level III care NICU between 01.12.2006 and 30.04.2008. All ELBW babies admitted during this period were assessed for morbidities and interventions required during NICU stay and for their outcome like survival or death. RESULTS: The survival rate of 87 ELBW babies admitted during this period was 56.1 %. Pulmonary hemorrhage was the commonest cause of death (25 %) followed by respiratory distress syndrome (22.5 %), intraventricular hemorrhage (22.5 %) and sepsis (20 %). Significantly higher number of non-survivors were <750 g at birth (p = 0.0001) and <28 wk gestation (p = 0.0001). Small for gestational babies had better chances of survival compared to those appropriate for gestational age (p = 0.005). RDS (67.8 %), probable sepsis (62.1 %) and hyperbilirubinemia (59.8 %) were the most frequent morbidities. Conventional ventilation (72.4 %) and nasal CPAP(48.3 %) were the commonest respiratory interventions. Surfactant replacement therapy was required in 47.1 % babies. CONCLUSIONS: ELBW babies have a major contribution to mortality in a NICU. Babies with birth weight <750 g and gestation <28 wk have poor survival. RDS, pulmonary hemorrhage, IVH and sepsis are the common causes of death while RDS, sepsis and hyperbilirubinemia are the most common morbidities.

Pune low birth weight study, growth from birth to adulthood.

OBJECTIVE: To assess the growth, adiposity and blood pressure of non-handicapped low birthweight children at 18 years. DESIGN: Prospective cohort study. SETTING: Infants born between 1987-1989 with birthweight less than 2000 g, discharged from a neonatal special care unit of a referral hospital and followed up till the age of 18 years. METHODS: The height, weight, and head circumference were measured. Measurements for adiposity, blood pressure, parental height and weight were recorded. RESULTS: The cohort of 161 low birth weight (LBW) infants was divided into three groups according to their gestation preterm SGA (n=61), full term SGA (n=30) and preterm AGA (n=70). 71 full term AGA infants served as controls. Preterm SGA males had height of 164.5 cms (162-166.9, 95% CI) which was significantly less (mean deficit = 5.7 cms) than that of controls (P=0.02). However, PTSGA children were short inspite of normal mid-parental height. Preterm SGA and AGA children had smaller head circumference. There was no evidence of adiposity and no child had hypertension. Mid-parental height was an important determinant of height in LBW children. Both parents weight and BMI were important determinants of weight and BMI, respectively in all LBW children. CONCLUSION: Preterm SGA males were short, but there was no difference in the weight of the LBW group and controls. Preterms had smaller head circumference. There was no evidence of adiposity or hypertension.

Neonatal intensive care practices harmful to the developing brain.

There has been a marked increase in the survival of extremely low birth weight (ELBW) infants, but these babies have a long stay in the NICU. Strategies to decrease their neurodevelopmental impairment become very important. The maximum development of the brain occurs between 29-41 weeks. From the warm, dark, acquatic econiche, where the baby hears pleasant sounds like the mother's heart beat, the baby suddenly finds itself in the dry, cold, excessively bright, noisy, environment of the NICU. Noise, bright light, painful procedures, and ill-timed caregiving activities, adversely affect the infant's development. Excessive radiation from X-rays of babies on the ventilator and CT scans also affect the brain. Medications like steroids for chronic lung disease also cause damage to the brain. Aminoglycides and frusemide are known to cause hearing impairment. Hence a developmentally supportive, humanized care will go a long way in enhancing the developmental outcome of these babies.

Transient tone abnormalities in high risk infants and cognitive outcome at five years.

OBJECTIVE: to identify transient tone abnormalities and determine its prevalence in high risk infants and their cognitive outcome at 5 years. DESIGN: prospective cohort observational study. SETTING: high risk infants discharged from a level II neonatal unit in a 12 month period, and followed upto 5 years. METHODS: High risk infants and normal controls were assessed for abnormalities of tone using the method described by Amiel Tison at 3, 6, 9, 12 months. An IQ by Stanford Binet method and a preschool inventory by Ayres, Bobath was done at 5 years. Those infants who had normal tone at 6 and 12 months were called normal high risk (HR) group and those who had abnormalities at 6 months, which disappeared at 12 months, were called the transient tone abnormalities (TTA) group. RESULTS: out of 190 high risk infants, 113 were normal HR and 67 (35.2%) were labeled as TTA. Ten infants with cerebral palsy had abnormal tone throughout the first year. Controls had normal tone throughout the follow-up period. Although there was no difference in the IQ of the TTA group (98.5 ± 12.4) and the normal HR (99.1 ± 13.1) group, it was significantly less (P=0.04) than that of controls (106.1 ± 9.1). Preschool inventory in TTA children showed poor language development (P=0.014). CONCLUSION: many of the tone abnormalities detected at 6 months resolve by 12 months, hence a hasty diagnosis of cerebral palsy should not be made. High risk infants with transient tone abnormalities have a normal cognitive outcome at 5 years, except for poor language skills.

Retinopathy of prematurity in a tertiary care center--incidence, risk factors and outcome.

OBJECTIVE: To study the incidence and risk factors predisposing to retinopathy of prematurity (ROP) and to assess the outcome after laser photocoagulation. DESIGN: Prospective cohort observational study. SETTING: Infants admitted to a neonatal intensive care unit of a referral hospital between 2000-2006 and followed up till the age of 3 years. METHODS: Preterm infants with birthweight<1500 g and gestationor=1500 g and gestation>32 weeks were screened only if they had additional risk factors. Those found to have threshold disease ROP had laser photocoagulation. They were recalled at 3 years and had a complete ophthalmic check up. RESULTS: The incidence of ROP in the 552 infants who were screened was 22.3%. No ROP was found in infants weighing>or=2000 g or with a gestational age more than 36 weeks. Risk factors predisposing to ROP were septicemia (P<0.001), apnea (P=0.0001) and oxygen therapy (P=0.031). Out of the 123 infants who had ROP, 41 (33.6%) needed laser photocoagulation. Twenty two (53.6%) were seen at 3 years of age. Ten children had myopia, 1 had amblyopia and 9 children had completely normal structural and visual outcome. Only two (9%) children were blind due to retinal detachment. CONCLUSION: One third of the infants with ROP needed laser photocoagulation, the outcome of which was good. Risk factors predisposing to ROP were septicemia, apnea, oxygen therapy and use of blood products.

Growth and sexual maturation of low birth weight infants at early adolescence.

OBJECTIVE: To assess the growth and sexual maturity of non-handicapped children with birth weight less than 2000 g at 12 years. DESIGN: Prospective cohort study. SETTING: Infants discharged from a Neonatal Special Care Unit of a referral hospital with birth weight less than 2000 g between 1987-1989 and followed up till the age of 12 years. METHODS: The height, weight and head circumference was measured. Sexual maturity was determined by Tanners score and age of menarche in girls was reported by parents. Parental height and weight was recorded. Intelligence quotient was determined by Weschslers Intelligence Scale. RESULTS: The cohort of 180 low birth weight (LBW) infants (birth weight less than 2000 g) was divided into 3 groups according to their gestation - preterm SGA (n=73), full term SGA (n=33) and preterm AGA (n=74). Ninety full term AGA infants served as controls. Preterm SGA children had significantly less height (mean deficit 5.8 cm), weight and head circumference (P<0.001). There was no significant difference in sexual maturity and onset of menarche between the study group and controls. There was a correlation between head circumference and IQ and preterm SGA children had the lowest mean IQ (85.4 +/- 17.7). Mothers height contributed 14% variance to a total variance of 25.3% for Z score of height at 12 years. Mothers weight contributed a variance 21.1% to a total variance of 29.4% for Z score of weight. CONCLUSION: Preterm SGA children were shorter, lighter and had the smallest head circumference, and also had the lowest IQ. Mothers height and weight was an important determinant of height and weight at 12 years.

Total parenteral nutrition in neonates.

Parenteral Nutrition (PN) allows us to meet a neonates requirement for growth and development when their size or condition precludes enteral feeding. Although feeding through the gastrointestinal tract is the preferred route for nutritional management, there are specific conditions where PN as an adjunctive or sole therapy is necessary. In very low birth weight premature infants, due to the immaturity of the gastrointestinal systems, enteral feeding cannot be established in the first few days of life. In critically ill neonates, neonates with protracted diarrhea and neonates who have had major GI surgery, PN can successfully meet the nutritional demands. Parenteral Nutrition solutions, although still evolving, have improved considerably since the early days and complications are now less common when amino acids and lipids are given in a dose of 1-3 g / kg / day. Meticulous attention to asepsis, good nursing care and close biochemical monitoring are absolutely essential for successful PN therapy.

Neurodevelopmental assessment in the first year with emphasis on evolution of tone.

Neurodevelopmental assessment in the first year of life is important for determining presence or absence of brain damage. Assessment of passive tone is essential for planning interventional therapy. One hundred infants with a normal antenatal, natal and perinatal course were prospectively followed up for one year. Social smile had appeared by 6 weeks in all infants, transfer of objects at 6 months, clapping by 9 months and scribbling on paper (imitative or spontaneous) by 12 months. Neonatal reflexes disappeared by 3 months, lateral propping appeared in all infants at 9 months, however parachute reflex appeared in 96.5% of 87 infants tested at 9 months. Measurement of passive tone by popliteal angle and adductor angle was done at 3, 6, 9, 12 months and scarf sign was also evaluated. The mean popliteal angle increased from 100.6 +/- 5.4 at 3 months to 136 +/- 4.0 at 12 months, whereas the adductor angle increased from 84.8 +/-6.5 to 126.6 +/- 5.3 degrees. The fast and the quick component of the dorsiflexion angle showed a difference of less than 10 at all testings. Assessment of active tone in the form of head support at 3 months was present in all the infants, 95% had pull to sit at 6 months and all 100% had pull to stand at 9 months.

Biology versus environment in low birth weight children.

OBJECTIVE: To explore the contribution of biologic risk factors versus socio-demographic and environmental risk factors in cognitive development of children with birth weight less than 2000 g, at the age of 12 years. DESIGN: Prospective cohort study. SETTING: Infants discharged from a NICU of a referral hospital, with birth weight less than 2000 g between 1987-89 and followed up in the High Risk Clinic. METHODS: The children were assessed at the age of 12 years, with the Weschler's Intelligence Scale for IQ and by Wide Range Achievement Test for mathematics skills. Mother's education, father's education, socio-economic status, family structure, spaciousness of the house, the locality in which the child lived and the type of school the child attended, were all recorded. A stimulation score was determined at 6 and 12 months and 3 years. Family environment score was used at 12 years. RESULTS: The cohort consisted of 180 children, with 90 controls. The mean IQ of the study group was 89.5 +- 16.9, which was significantly lower than that of controls (97.2 +- 14.1) (P < 0.05). The mathematical skills of the study group were significantly poorer (P < 0.05) than that of controls. A multiple linear regression analysis was done using IQ as the dependent variable and all risk factors at birth, stimulation scores and socio-environmental factors as independent variables. Mothers education was the most important factor contributing to the total IQ, a variance of 25.2 % of the total variance 44.2 PERCENT. Fathers education emerged as an important factor for mathematics skills. School was the next important factor for IQ as well as academics. Controlling for all other background factors, birth weight was the only biologic factor of significance, and this had a very small contribution. CONCLUSION: Parental education and the type of school attended by the child were the most important factors influencing cognitive development. The only biologic factor of importance was birth weight, but this too had a very small contribution.

Safety profile of ciprofloxacin used for neonatal septicemia.

We conducted a case matched control study to observe the adverse effects of ciprofloxacin used in neonatal septicemia We enrolled 30 neonates with multidrug-resistant septicemia who were treated with intravenous ciprofloxacin for 14 days. Thirty matched neonates with septicemia treated with other antibiotics were enrolled as controls There was no difference in the mean serum electrolytes, hepatic, renal and hematologic parameters of the two groups. Serial ultrasonographic measurements of the cartilage of the knee after 1 and 6 months showed no difference in the two groups. The femoral cartilage showed an increase of 78.8% in the mean longitudinal area after 6 months in the study group. In the control group, the femoral cartilage showed a 78.4% increase after 6 months. Similarly, the tibial cartilage showed no difference in the percentage increase in size of the study and control group at the end of 6 months. When controlled for birth weight and gestation, cartilage size was not affected by ciprofloxacin.

Pune low birth weight study--cognitive abilities and educational performance at twelve years.

OBJECTIVE: To assess the intelligence, visuo-motor perception, motor competence and school performance of children with birth weight less than 2000 grams, at the age of 12 years. DESIGN: Prospective cohort study. SETTING: Infants discharged from a Neonatal Special Care Unit of a referral hospital with birth weight less than 2000 g between 1987-89 and followed up in the High Risk Clinic. METHODS: The children were assessed by the Weschler's Intelligence Scale, Bender Gestalt test for visuo-motor perception, Wide Range Achievement Test for specific learning disability, Draw-a-Person screening test for emotional problems and Movement Assessment Battery for motor competence. Academic achievement was also scrutinised. RESULTS: One hundred and eighty children weighing less than 2000 grams at birth and ninety control children were assessed. The mean IQ of the study group was normal (89.5 +/- 16.9), though significantly lower than that of controls (97.2 +/- 14.1; p<0.05). Pre term SGA children had the lowest mean IQ (85.4 +/- 17.7). In the 78 VLBW children, there were 12 (15.4%) mentally retarded children as compared to only 3 (3.3%) amongst controls (p<0.001). There were only 3 (3.8%) 'bright' children among the VLBW group, as compared to 20 (22.2%) in the control group (p<0.001). Visuo-motor perception and motor competence of the study group was poor, and they had writing and mathematics learning disability, especially the preterm SGA and VLBW group. Academic achievement was poor and the incidence of borderline intelligence was 24.4%, which has increased from 13.4% at 6 years. CONCLUSIONS: The intelligence and academic performance of the children weighing less than 2000 grams is significantly lower than that of controls, though within normal limits. They also have poor visuo-motor perception, motor incompetence, reading and mathematics learning disability. The preterm SGA and VLBW children had the poorest cognitive abilities.