Impact of family structure and stability on academic outcome in preterm children at 10 years of age.

OBJECTIVE: To compare school performance at age 10 years in a cohort of extremely preterm children and term control subjects and to examine the impact of family composition and stability on performance. STUDY DESIGN: Prospective, longitudinal follow-up from birth to 10 years of age of a regional cohort of children born at 24 to 31 weeks of gestational age and sociodemographically matched term control subjects. Family composition, extent of parental care giving, and family moves were tracked sequentially. At 10 years, academic achievement and school performance were ascertained for 118 of 125 (94%) preterm survivors and 119 of 125 (95%) term children. RESULTS: Term children were more likely to demonstrate optimal school outcome (appropriate grade level without additional classroom assistance) than were preterm children (odds ratio 3.4, 95% CI 1.9-6.0). Medical complications related to prematurity had little impact on school outcome. Among preterm children, optimal school outcome was significantly associated with increased parental education, child rearing by 2 parents (regardless of marital status), and stability in family composition and geographic residence over 10 years. These environmental influences were less pronounced among term control subjects. CONCLUSION: Although preterm children performed less well in school than term children, family factors were stronger predictors of school performance than were perinatal complications.

Perinatal information systems for quality improvement: visions for today.

Today clinical information is used for a multitude of purposes beyond patient care documentation including quality review and improvement processes, allocation of resources, budgetary and long-term planning, productivity measurement, and justification to payers for services provided. Providers in perinatal medicine are faced with the challenge of finding methods to meet these information needs. Case examples of the different approaches to collecting and using obstetric and neonatal information are described. The role of computer-based patient records is outlined and solutions available to perinatal medicine are reviewed.

Reducing blood donor exposures in low birth weight infants by the use of older, unwashed packed red blood cells.

We performed a prospective, randomized masked trial to determine whether the use of dedicated units of packed red blood cells equipped with seven satellite bags would reduce donor exposures in infants with birth weights < 1500 gm. We also examined the use of unwashed and older red blood cells. Red blood cells given to the study group were used without washing and until their expiration date (35 to 42 days). Changes in blood pH, potassium, ionized calcium, and hemoglobin were determined with each transfusion and compared with data collected from a control group that received washed, younger red blood cells. There was a 64% reduction in donor exposures in the study group. Changes in infants' blood pH and calcium levels with transfusion were the same in the two groups. There was a clinically unimportant difference in potassium levels. A greater rise in hemoglobin values occurred when washed cells were used. There was no correlation between changes in the blood levels measured and the age of unwashed cells infused. We conclude that the use of red blood cells from satellite bag-equipped dedicated units decreases donor exposures, and that the practices of using only younger red blood cells and of saline washing of red blood cells before infusion, are unwarranted.

Developmental outcome of preterm infants with transient neuromotor abnormalities.

OBJECTIVE: To determine the relationship between transiently abnormal neurologic findings in preterm infants and subsequent cognitive outcome at 4 years of age. DESIGN: Prospective 4-year follow-up. SETTING: Regional perinatal center in Syracuse, NY. PARTICIPANTS: One hundred thirty-one of 135 consecutively born infants of no more than 32 weeks of gestational age; 98% followed up from birth to 4 years of age. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Based on neuromotor evaluations performed at 6 and 15 months of age, two groups of infants were identified. One group had abnormal neurologic findings at 6 months of age that had resolved by 15 months of age (transiently abnormal group). The other group had normal neuromotor findings at both 6 and 15 months of age (normal group). The transiently abnormal group had significantly poorer scores on the Bayley Mental scale at 6 months of age (90 +/- 15 vs 108 +/- 10; P < .001), 15 months (91 +/- 21 vs 105 +/- 12; P < .001), and 24 months (91 +/- 19 vs 101 +/- 17; P < .001). However, at 4 years of age, cognitive performance on the McCarthy Scales was similar for the transiently abnormal and normal groups (General Cognitive index, 93 +/- 13 and 95 +/- 14, respectively). The incidence of poor cognitive outcome (Cognitive index < 84) decreased from 39% at 2 years of age to 18% at 4 years of age in the group with a history of transient neurologic abnormalities but remained unchanged (16% to 18%) in the normal group. CONCLUSION: Early neurologic abnormalities that are transient did not predict cognitive delays at 4 years of age in preterm infants.

Feeding the low birth weight infant.

A true gold standard for assessing the nutritional outcome of preterm infants remains elusive. We are seeing an expansion beyond the traditional intrauterine-based short-term growth and nutrient retention rates toward a broader, and possibly life-long, range of outcomes. As our nutritional end points shift, the suitability of the preterm infants' own mothers' milk may become more apparent. Whether the unique properties of human milk or the use of human milk components for fortification are sufficient to rekindle the use of donor milk from milk banks remains to be seen. Improved formulas designed specifically for preterm infants and the possibility of providing passive immunity in formula have added fuel to the debate over what constitutes an ideal nutrient source. The optimal time to begin to feed our smallest and sickest patients is being reevaluated. A policy of exclusive parenteral nutrition for prolonged periods of time may be replaced with one in which minimal amounts of feeding are used, in conjunction with parenteral support, to prepare and maintain intestinal function until advancements toward full enteral nutrition are possible. Although well-controlled trials are needed to add substance to our decisions on many feeding methods, such as intermittent bolus versus continuous gastric infusion, the use of transpyloric feeding should be discouraged. Finally, we need to determine if there are any tangible nutritional benefits from the use of nonnutritive sucking. It is hoped that resolution of some of the controversies of feeding preterm infants will broaden our clinical view of infant nutrition. The discussion on work rounds will then move away from the current "did the baby get 120 kcal/kg yesterday?" toward an informed discussion of how, what, when, and why to feed the infant. Over a century ago, Abraham Jacopi cautioned pediatricians that "You cannot feed a baby with mathematics; you must feed them with brains."

Database use in neonatal intensive care units: success or failure.

The purpose of this national survey was to define the extent and features of database use by 445 tertiary level neonatal intensive care nurseries in the United States. Of the 305 centers responding to our survey, 78% had a database in use in 1989 and 15% planned to develop one in the future. Nurseries varied remarkably in the volume of data collected, the amount of time devoted to completing data collection forms, and the personnel involved in data collection. Although data were used primarily for statistical reports (93% of nurseries), quality assurance (73%) and research activities (61%) were also enhanced by database information. Neonatal databases were used to generate reports for the permanent medical record in 38% of centers. Satisfaction with the database was dependent on how useful the database information was to centers which collected and actually used a large volume of information. Overall, nurseries expressed a high degree of confidence in the data they collected, and 65% felt their neonatal database information could be used directly in publication of research. It was disturbing that accuracy of data was not monitored formally by the majority of nurseries. Only 27% of centers followed a routine schedule of data quality assurance, and only 53% had built in error messages for data entry. We caution all who receive database information in the form of morbidity and mortality statistics, clinical reports on patients cared for in neonatal units, and published manuscripts to be attentive to the quality of the data they consume. We feel that future database design efforts need to better address data quality control. Our findings stress the importance and need for immediate efforts to better address database quality control.

Impact of a matched term control group on interpretation of developmental performance in preterm infants.

One hundred twenty-four children who were born at 24 to 31 weeks' gestation and 124 term children matched in social background underwent serial developmental evaluations. The Bayley Mental Developmental Index at 6, 15, and 24 months and the McCarthy General Cognitive Index at 4 years were used to classify cognitive outcome for preterm children as normal (indices higher than 1 SD below the mean), mild-moderately delayed (indices between 1 and 2 SD below the mean), or severely delayed (indices > or = 2 SD below the mean). Classifications based on norms derived from the performance of the term control group were compared with those based on published standardized test scores. The control group had substantially higher mean (+/- SD) Bayley Mental Developmental Indices at 6 (111 +/- 11), 15 (114 +/- 13), and 24 months (115 +/- 21) than the published test mean (100 +/- 16). Consequently, significantly more preterm children were classified as normal when the Bayley test mean was used than when the performance of the control group was used to define the normal range (84% vs 52% at 6 months, 82% vs 49% at 15 months, and 70% vs 47% at 24 months). Severe cognitive delays were infrequent when defined by test mean (6% to 11%) but two to three times greater when the control group scores were used. In contrast, the control group had a mean McCarthy General Cognitive Index at 4 years (102 +/- 14) that was similar to the published test mean (100 +/- 16).(ABSTRACT TRUNCATED AT 250 WORDS)

Cingulate sulcus development in preterm infants.

Cranial ultrasounds performed during the first 3 d of life on 211 infants of 24 to 40 wk gestational age were examined to determine the in utero development of the cingulate sulcus. The sulcus was identified between 24 and 28 wk of gestational age as fragmented echoes in the region between the thalamus and the anterior fontanelle. Over the next several weeks, these fragments coalesced into a single linear echo. Branches then appeared off of the primary cingulate sulcus, increasing in number until a complex pattern of branching was noted near term gestation. This maturational sequence was similar to postnatal cortical development determined from serial ultrasounds performed on 144 infants who were less than or equal to 32 wk of gestational age at birth. The timing of postconceptional cingulate sulcus development was independent of gestational age at birth. However, severe brain insult, defined as intraventricular hemorrhage complicated by ventriculomegaly or intraparenchymal extension or periventricular leukomalacia, was associated with significant delays in all stages of cingulate sulcus development. Cranial ultrasound examinations in preterm infants allow a noninvasive means of staging qualitative brain development during the early postnatal period.

Routine endotracheal cultures for the prediction of sepsis in ventilated babies.

Serial cultures of endotracheal tube aspirates were carried out in 94 neonates who were intubated and had been ventilated for longer than one week. A similar change in bacterial colonisation with duration of ventilation was seen in infants who subsequently developed sepsis and those who did not. In both groups, 177 aspirates (more than 90%) obtained during the first week of ventilation were sterile. Thereafter, colonisation with mixed Gram positive flora emerged followed by growth of Gram negative bacilli. For the infants who developed sepsis, the correlation between pathogens isolated from blood during the episodes of sepsis and those from previous endotracheal tube isolates was poor; in only five of the 26 cases of sepsis (19%) was the same single strain of organism isolated from culture of the blood and of the endotracheal tube aspirate. Other markers of infection such as endotracheal tube aspirate white blood cell counts and changes in bacterial flora were not useful in predicting systemic infection. Routine surveillance cultures of endotracheal tube aspirates in ventilated infants are not helpful in predicting the pathogens that are isolated from the blood during episodes of sepsis.

Effect of early low-volume enteral substrate on subsequent feeding tolerance in very low birth weight infants.

To determine the effect of small enteral feedings on small bowel function, 46 infants with birth weight less than 1500 g, selected on the basis of risk factors for feeding intolerance, were assigned randomly to one of two feeding groups. Group 1 received low-volume enteral feeds (12 ml/kg/day) in addition to parenteral alimentation for 10 days beginning on day 8 of life; group 2 received parenteral alimentation alone until day 18 of life. After this trial period feedings were increased by 15 ml/kg/day in all infants. Four infants (9%) developed necrotizing enterocolitis (one prior to any feeds, two in group 1, and one in group 2); two others were dropped from the study for reasons unrelated to feeding. The remaining 18 infants in group 1 had improved feeding tolerance compared with the 22 in group 2, as manifested by fewer days that gastric residuum totalled more than 10% of feedings (1.3 +/- 0.5 days vs 3.2 +/- 0.6 days, respectively, p less than 0.05) and fewer days that feedings were discontinued because of feeding intolerance (2.7 +/- 0.8 days vs 5.5 +/- 0.9 days, respectively, p less than 0.05). Consequently, 17 of 18 (94%) infants who had received the early low-volume enteral feedings achieved an enteral intake of 120 kcal/kg/day by 6 weeks of life, whereas only 14 of 22 (64%) infants in the delayed feeding group reached this intake (p less than 0.05). Peak total serum bilirubin concentrations were comparable in the two groups. The initiation of hypocaloric enteral substrate as an adjunct to parenteral nutrition improved subsequent feeding tolerance in sick infants with very low birth weight.

Solitary rectal ulcer syndrome in a teenaged boy.

Since the original description of solitary rectal ulcer by Cruveilheir in 1830, about 250 cases have been reported (1). The condition most frequently presents in adults between 30 and 50 years of age. There are very few pediatric case reports and none have come from North America. We report here a 13-year-old boy with solitary rectal ulcer syndrome and a review of the pediatric experience with this rare condition.