A pilot study on cord blood levels of erythropoietin and its relationship to periventricular leukomalacia in preterm infants.

This article reports the results of a study on the relationship between cord blood levels of erythropoietin and periventricular leukomalacia. Cord blood was obtained from 19 infants with gestational age between 27 and 32 weeks. Cystic periventricular leukomalacia was seen in 4 of them. Erythropoietin levels were not different between those with and those without periventricular leukomalacia.

A new method of blood sampling reduces pain for newborn infants: a prospective, randomized controlled clinical trial.

BACKGROUND: Using a new simple blood glucose measurement device (Free Style), blood can thus be sampled from the forearm, which is less sensitive to pain than from the heel. Measuring the blood glucose levels in newborn infants using Free Style is therefore a potentially less painful testing modality than traditional blood sampling methods. OBJECTIVE: To compare the pain intensity at the time of blood sampling from the forearm using the Free Style with the conventional method from the heel. DESIGN: A prospective, randomized controlled clinical trial. PATIENTS AND METHODS: Sixty healthy neonates were randomized by the sealed envelope method into two groups-Group F, in which blood was sampled from the forearm using the Free Style, and Group H, in which blood was conventionally sampled from the heel using a lancet. The pain intensity was assessed based on their crying, the Neonatal Facial Coding System (NFCS) and the Neonatal Infant Pain Scale (NIPS). RESULTS: After skin puncture, 12 (40%) of the infants cried in Group F and 27 (90%) in Group H. The duration of crying was also significantly shorter in Group F than in Group H. Both of pain scores between the two groups differed significantly, these findings indicated less pain for Group F. CONCLUSION: The new blood sampling method from the forearm was found to be less painful than the conventional method, thus making it possible to clinically use this product as an innovative method for blood sampling in neonatal medicine.

Serial diffusion-weighted imaging of neonatal herpes encephalitis: a case report.

We reported a patient with neonatal herpes simplex encephalitis in whom diffusion-weighted imaging was performed repeatedly. Diffusion-weighted imaging at 20h after the onset of seizures revealed scattered small spotty high intensity lesions in both hemispheres and a high intensity area in the left fronto-temporal lobe. There was no abnormal finding on conventional magnetic resonance imaging. Second diffusion-weighted imaging 72h after the onset revealed expanded scattered high intensity lesions in the bilateral hemisphere, a high intensity area in the left fronto-temporal lobe, and a new high intensity area in the right temporal lobe. There was no report on neonatal herpes simplex encephalitis that showed scattered high intensities in diffusion-weighted imaging. Scattered small high intensities on diffusion-weighted imaging may suggest endothelial cell infection with swelling and small vessel necrosis. Early diffusion-weighted imaging will be valuable for early detection and diagnosis of neonatal herpes simplex encephalitis.

Mild oliguria in preterm infants who later developed periventricular leukomalacia.

The aim of this study is to determine whether or not renal involvement was present during the early neonatal period in preterm infants with PVL. We conducted a case-control study. The following items were evaluated; urine output, serum levels of sodium (Na), potassium (K), chloride (Cl), urea nitrogen (UN), and creatinine (Cr). The factors that could influence the urine output were also compared between the PVL and the control group. The mean urine output during the first 24h in the PVL group was 19.8ml/kg/day, and was significantly lower than in the control group (28.8ml/kg/day, p<0.05). The mean UN and Cr were not significantly different between the two groups. The minimal serum Na and Cl levels in the PVL group were significantly lower (128.3 and 94.3mEq/l) than those in the control group (134.8 and 100.7mEq/l, p<0.01 each). The maximal serum K level was significantly higher in the PVL group (6.47mEq/l) as compared to the control group (5.57mEq/l, p<0.05). There were no differences in any postnatal variables between the two groups. The preterm infants who later developed PVL had mild but significant oliguria during the first 24h of life. This suggests that preterm infants with PVL will have renal involvement immediately after birth.

Efficacy and adverse effects of rectal thiamylal with oral triclofos for children undergoing magnetic resonance imaging.

We studied the efficacy and adverse effects of rectal thiamylal in combination with oral triclofos in sedation for pediatric magnetic resonance imaging. Five hundred forty-six children underwent MRI examination from January of 1997 to December of 2001. Among them, 10mg/kg of rectal thiamylal was administrated after oral triclofos in 378 children. Successful sedation was obtained in 321 of 378 patients (85%) after a single rectal administration of thiamylal. Totally, 369 children (98%) could undergo MRI examination completely under successful sedation. Adverse effect was observed only in one patient showing respiratory depression. Rectal thiamylal is effective for sedation for MRI in children. Adverse effect was rare in our patients. Although the risk of side effect was considered to be rare, we should follow principles for the sedation of children.

[Subacute encephalitis/encephalopathy with residual cognitive deficit].

We studied clinical features of 5 patients with subacute encephalitis/encephalopathy with residual cognitive deficit. In all patients, impairment of consciousness was mild at the onset, progressed between 4 and 15 days after the onset, and reached its peak at 6-18 days after the onset. Neuroradiological or electrophysiological examinations at the onset showed normal or mildly abnormal findings. In accordance with the clinical deterioration, brain atrophy was detected on cranial magetic resonance imaging (MRI) in 3 patients, and electroencephalogram revealed slowing of the background activities in all patients. Single photon emission computed tomography (SPECT) showed hypoperfusion in the fronto-temporal areas in all patients at the recovery stage. Three patients had severe mental deficits, and the other two had mild cognitive deficit. Motor impairment was observed in one patient.

The evolutionary change of flash visual evoked potentials in preterm infants with periventricular leukomalacia.

OBJECTIVE: The aim of this study was to prospectively investigate flash visual evoked potential (VEP) findings and their chronological changes in preterm infants with cystic periventricular leukomalacia (PVL) during the early neonatal period. METHODS: The subjects of this study were 14 preterm infants with cystic PVL. The patients underwent serial cranial ultrasonography and diagnosed as having cystic PVL. Flash VEPs were diagnosed at least twice within the first 3 weeks of life. RESULTS: All infants had at least one or more flash VEP abnormalities. The most common finding was 'absent VEP', which was seen in 13 infants (93%). 'Delayed latency' was seen in two infants and 'abnormal waveform' was seen in one infant. Concerning the chronological changes, all records were abnormal in 4 infants, and the other 10 had transient normal VEP findings. Among them, flash VEPs changed from normal to abnormal within 10 days after birth in most cases. CONCLUSIONS: Almost all infants with cystic PVL had abnormal flash VEPs within the first 3 weeks of life, but chronological changes of flash VEP findings were seen during the period. SIGNIFICANCE: This manuscript may be useful as a reference to the flash VEPs in preterm infants with cystic PVL.

Popliteal angle in preterm infants with periventricular leukomalacia.

The aim of this study is to clarify the usefulness of popliteal angle in infants with periventricular leukomalacia. The popliteal angle was measured at 1, 4, 8, and 12 months of corrected age in 47 infants with periventricular leukomalacia and in 103 control infants with normal development. The popliteal angle was categorized into two groups; tight, when it was < or =120 degrees , and wide, when it was >120 degrees . The severity of diplegia was defined at 2 years as follows: mild, when an infant could walk; moderate, when an infant could sit but could not walk; severe, when an infant could not sit. Tight popliteal angle was more often observed in infants with periventricular leukomalacia than in normal infants at any corrected age. The rate of tight popliteal angle was significantly lower in infants with mild diplegia than in those with moderate or severe diplegia at 8 and 12 months of corrected age. Specificity and positive predictive value were high at 8 and 12 months of corrected age, whereas sensitivity was relatively low. The results of this study suggest that evaluation of popliteal angle is useful for detection of infants with periventricular leukomalacia, although false-negative rate is high during late infancy.

Popliteal angle of low birth weight infants during the first year of life.

The aim of this study is to clarify the evolutional changes of the popliteal angle in low birth weight infants during the first year of life. The popliteal angle was measured at 1, 4, 8, and 12 months of corrected age on routine physical examination of 204 appropriate-for-date infants who had achieved normal psychomotor development. The popliteal angle was visually determined and categorized into two groups; tight, when it was 120 degrees or less, and wide, when it was more than 120 degrees. The infants were divided into five groups according to their birth weights; Group E, birth weight or=2500 gm. At 4 months of corrected age, the rate of a tight popliteal angle was significantly higher in Groups E + V + L1 than in Groups L2 + N. A tight popliteal angle was rare in all groups at 8 or 12 months of age. The results of this study indicate that the physiologic muscle tone of lower extremities is higher in infants with birth weights of <2000 gm at 4 months of corrected age. One should carefully interpret a tight popliteal angle in low birth weight infants during early infancy. Serial assessment of the popliteal angle is necessary before judging that a low birth weight infant has spastic cerebral palsy.

Abnormal sharp transients on electroencephalograms in preterm infants with periventricular leukomalacia.

OBJECTIVE: To determine the clinical significance of abnormal sharp transients other than positive rolandic sharp waves (PRS), electroencephalograms were used for the diagnosis of periventricular leukomalacia (PVL). STUDY DESIGN: We evaluated 126 electroencephalograms from 93 preterm infants; 31 infants had PVL, and 62 were control infants. Frontal sharp waves (FS) were defined as sharp transients of positive polarity with an amplitude >100 microV. Occipital sharp waves (OS) were defined as those of negative polarity with an amplitude >150 microV. FS, OS, or PRS were considered to be present when there were >0.1 per minute. RESULTS: The number of FS per minute was significantly higher in the PVL group than in the control group during days 0 to 4 and 5 to 7. The number of OS per minute was also significantly higher in the PVL group than in the control group during days 0 to 4, 5 to 7, and 8 to 14. The sensitivity of FS or OS was relatively high but that of PRS was low. The presence of two or more types of abnormal sharp transients was correlated with a poor outcome. CONCLUSIONS: FS or OS may be useful for predicting which infant will have PVL.

Hypoxic ischemic encephalopathy associated with neonatal seizures without other neurological abnormalities.

We reported three term or near-term infants with parasagittal infarcts. Their Apgar scores were low and the amniotic fluid was meconium-stained. Resuscitation was necessary immediately after birth, but they were not stuporous and no neurological abnormalities were recognized on admission. They showed metabolic acidosis and transient hypoglycemia, and two showed hematoemesis. Seizures were observed between 2 and 15 h of age in all of them. Electroencephalography demonstrated moderate or severe depression, and CT demonstrated bilateral abnormal low densities in the border zones of the middle and posterior cerebral arteries. Two of them had mental retardation and epilepsy, although the other exhibited normal development. Our infants suggest that neonatal seizures can also occur in infants with hypoxic ischemic encephalopathy without apparent neurological abnormalities.

Developmental outcome and types of chronic-stage EEG abnormalities in preterm infants.

The aims of this study were to determine the types of chronic-stage EEG abnormalities that exist and to clarify their relation to neurodevelopmental outcome in preterm infants. We evaluated 183 preterm infants with gestational ages of less than 33 weeks (mean age 29.2 weeks) and weighing less than 2000 g (mean weight 1275 g). The first EEG was performed within 72 hours of life; thereafter, EEG was performed once every 1 to 4 weeks until the infant reached a post-conceptional age of 40 to 42 weeks. Two kinds of EEG abnormalities, acute- and chronic-stage abnormalities, were evaluated and we assessed mainly the latter. Chronic-stage EEG abnormalities were divided into two patterns: disorganized and dysmature. Periventricular leukomalacia (PVL) and intraventricular haemorrhage (IVH) were diagnosed on the basis of ultrasound findings. Psychomotor development was examined every 3 months after discharge until at least 18 months of the infants' corrected age. Disorganized and dysmature patterns were observed in 52 and 28 infants respectively. Among the 52 infants with disorganized patterns, PVL was observed in 31 and IVH in seven infants. Thirty-nine infants had cerebral palsy (CP). Twenty-six achieved normal cognitive development. Of the 28 infants with dysmature patterns, PVL was seen in one and IVH in 11 infants. CP was seen in five infants. Only eight infants achieved normal cognitive development. Gestational age and birthweight were significantly lower in infants with dysmature patterns than in those with disorganized ones. Results indicate that types of chronic-stage EEG abnormalities are related to types of neurological sequelae and are useful for assessing the mode of brain injury in preterm infants.

Combination of neonatal electroencephalography and ultrasonography: sensitive means of early diagnosis of periventricular leukomalacia.

This study was performed to assess the predictive value of ultrasonography and electroencephalography (EEG) in order to identify infants with periventricular leukomalacia (PVL) during the early neonatal period, especially non-cystic cases, and to clarify the combination of ultrasonographic and EEG findings that are the most useful. We studied 288 eligible infants, whose gestational ages ranged between 27 and 32 weeks. PVL was observed in 49 infants (26 cystic PVL and 23 non-cystic PVL). On ultrasonography, 31 infants with PVL were detected on the basis of definite periventricular echodensity (PVE). Thirty-seven infants had at least one of equivocal or definite PVE or cystic changes, but the other 12 did not have any of them. The sensitivity and specificity were 0.76 and 0.81, respectively. In EEG findings, acute stage abnormalities (ASA) of grade II or more were recognized in 31 infants with PVL. The sensitivity and specificity were 0.63 and 0.91, respectively. Equivocal or definite chronic stage abnormalities (CSA) were seen in 43 infants, the sensitivity and specificity being 0.88 and 0.84. The sensitivity of CSA was higher than that of ASA, and the specificity of ASA was higher than that of CSA. When these EEG findings were combined, 45 infants with PVL were detected. The sensitivity, specificity, positive predictive value, and negative predictive value were 0.92, 0.77, 0.45, and 0.98, respectively. Moreover, ultrasonographic and EEG findings were combined, 46 out of the 49 infants with PVL were detected with a sensitivity of 0.94 and a specificity of 0.64. The results indicated that EEG may be suitable for detecting infants at risk for development of PVL on the basis of its high sensitivity, and ultrasonography may be useful for confirming the presence of PVL on the grounds of its high specificity. Appropriate use of these measurements will make an early diagnosis of infants with PVL possible, even in non-cystic cases.

Cerebral hemodynamics during early neonatal period in preterm infants with periventricular leukomalacia.

We prospectively investigated the relation among cerebral blood flow, periventricular leukomalacia (PVL) and hypocarbia using Doppler ultrasonography in 53 preterm infants with gestational age between 27 and 34 weeks who required mechanical ventilation during the first 72 h of life. Cerebral blood flow of pericallosal artery was assessed by Doppler ultrasonography at the first and the third day of life. Mean velocity (MV) and Resistance index (RI) of anterior cerebral artery were calculated from the data obtained by Doppler ultrasonography. The diagnosis of PVL was made in 12 infants on the basis of the results of ultrasonography and MRI. Hypocarbia was judged as positive when both arterial blood gas analyses before and after the ultrasonography revealed PaCO(2) values < 25 mmHg. On the first day of life, RI was 0.62 +/- 0.022 in infants with PVL and 0.71 +/- 0.014 in those without PVL. On the third day of life, RI was 0.60 +/- 0.032 in infants with PVL and 0.66 +/- 0.013 in those without PVL. There was a significant difference in RI between the two groups at either point. MV was not significantly different between the two groups at either point. There was no significant difference in RI or MV between infants with and without hypocarbia at either point. RI was significantly lower in infants with PVL during the first 72 h of life, which is suggestive of vasoparalysis in such infants at the level of major cerebral arteries. However, RI or MV was no different between infants with and without hypocarbia.

A pilot study on umbilical venous level of natriuretic peptides in preterm infants and their relation to periventricular leukomalacia and antenatal complications.

The aim of this study was to determine the relation between umbilical venous levels of atrial natriuretic peptide (ANP) and brain natriuretic peptide (BNP) in preterm infants, and the development of periventricular leukomalacia (PVL) and antenatal complications. Umbilical venous blood samples were obtained from 19 preterm infants with gestational age between 27 and 32 weeks. Cystic PVL was seen in four of them on ultrasonography. Several maternal variables were also investigated. There were no significant differences in ANP or BNP level between infants with and without PVL. Both ANP and BNP levels were significantly higher in infants with antenatal magnesium administration than in those without. Umbilical venous levels of natriuretic peptides were not useful to predict neurological outcome in preterm infants.