Protecting the brain of the micropreemie.

Advances in perinatal care have seen substantial improvements in survival without disability for extremely preterm infants. Protecting the developing brain and reducing neurodevelopmental sequelae of extremely preterm birth are strategic priorities for both research and clinical care. A number of evidence-based interventions exist for neuroprotection in micropreemies, inclusive of prevention of preterm birth and multiple births with implantation of only one embryo during in vitro fertilisation, as well as antenatal care to optimize fetal wellbeing, strategies for supporting neonatal transition, and neuroprotective developmental care. Avoidance of complications that trigger ischemia and inflammation is vital for minimizing brain dysmaturation and injury, particularly of the white matter. Neurodevelopmental surveillance, early diagnosis of cerebral palsy and early intervention are essential for optimizing long-term outcomes and quality of life. Research priorities include further evaluation of putative neuroprotective agents, and investigation of common neonatal interventions in trials adequately powered to assess neurodevelopmental outcome.

Epidemiology and pathogenesis of stroke in preterm infants: A systematic review.

BACKGROUND: Perinatal stroke is one of the principal causes of cerebral palsy (CP) in preterm infants. Stroke in preterm infants is different from stroke in term infants, given the differences in brain maturation and the mechanisms of injury exclusive to the immature brain. We conducted a systematic review to explore the epidemiology and pathogenesis of periventricular hemorrhagic infarction (PVHI), perinatal arterial ischemic stroke (PAIS) and cerebral sinovenous thrombosis (CSVT) in preterm infants. METHODS: Studies were identified based on predefined study criteria from MEDLINE, EMBASE, SCOPUS and WEB OF SCIENCE electronic databases from 2000 -2019. Results were combined using descriptive statistics. RESULTS: Fourteen studies encompassed 546 stroke cases in preterm infants between 23 -36 weeks gestational ages and birth weights between 450 -3500 grams. Eighty percent (436/546) of the stroke cases were PVHI, 17%(93/546) were PAIS and 3%(17/546) were CSVT. Parietal PVHI was more common than temporal and frontal lobe PVHI. For PAIS, left middle cerebral artery (MCA) was more common than right MCA or cerebellar stroke. For CSVT partial or complete thrombosis in the transverse sinus was universal. All cases included multiple possible risk factors, but the data were discordant precluding aggregation within a meta-analysis. CONCLUSION: This systematic review confirms paucity of data regarding the etiology and the precise causal pathway of stroke in preterm infants. Moreover, the preterm infants unlike the term infants do not typically present with seizures. Hence high index of clinical suspicion and routine cUS will assist in the timely diagnosis and understanding of stroke in this population.

First Molecular Detection and Phylogenetic Analysis of Ehrlichia canis in Dogs from Baghdad, Iraq.

Ehrlichia canis is a pathogen considered a disease in both dogs and breeders, a tropical and non-tropical disease caused by an intracellular pathogen. For the first time, the study aimed at hematological and molecular detection and phylogenetic analysis of Erlchcia canis in dogs in Baghdad, Iraq. Two hundred dogs were clinically examined from April to September 2019 at the Veterinary Hospital in Baghdad. Blood samples with EDTA tubes were used for microscopic examination, complete blood count (CBC) and polymerase chain reaction (PCR). The study's results revealed that the infection rate was 3.5% when analyzed using microscopic or molecular methods. Ataxia, posterior recumbency, and occasionally vision problems were identified as the clinical characteristics that were distinguished in this study. The hematological values showed no significant differences between infected and uninfected dogs (P>0.05). However, the study did show that infected dogs had neutrophilia and monocytosis. Four samples were sent to the sequencers, and NCBI accession numbers were assigned to two isolates of the Ehrlichia canis 16s rRNA gene (MN227483.1 and MN227484.1). This study showed that 99% of the isolates matched those found in other countries. The study concluded that microscopic examination is not the best method for diagnosing Ehrlichia in dogs because it requires the ability to differentiate microscopically between intracellular inclusion bodies and the included morula of Ehrlichia and may produce incorrect results. Instead, molecular tests are used to confirm an Ehrlichia diagnosis.

Neonatal encephalopathy: Focus on epidemiology and underexplored aspects of etiology.

Neonatal Encephalopathy (NE) is a neurologic syndrome in term and near-term infants who have depressed consciousness, difficulty initiating and maintaining respiration, and often abnormal tone, reflexes and neonatal seizures in varying combinations. Moderate/severe NE affects 0.5-3/1000 live births in high-income countries, more in low- and middle-income countries, and carries high risk of mortality or disability, including cerebral palsy. Reduced blood flow and/or oxygenation around the time of birth, as with ruptured uterus, placental abruption or umbilical cord prolapse can cause NE. This subset of NE, with accompanying low Apgar scores and acidemia, is termed Hypoxic-Ischemic Encephalopathy. Other causes of NE that can present similarly, include infections, inflammation, toxins, metabolic disease, stroke, placental disease, and genetic disorders. Aberrant fetal growth and congenital anomalies are strongly associated with NE, suggesting a major role for maldevelopment. As new tools for differential diagnosis emerge, their application for prevention, individualized treatment and prognostication will require further systematic studies of etiology of NE.

'Flower of the body': menstrual experiences and needs of young adolescent women with cerebral palsy in Bangladesh, and their mothers providing menstrual support.

BACKGROUND: This study offers voice to young adolescent women with cerebral palsy (CP) in Bangladesh as they describe their menstrual experiences and needs, and their mothers providing menstrual support. METHOD: Semi-structured focus groups with adolescents with CP, and separately their mother. Data was analysed using a material discursive framework and drawing on feminist disability theory. Participants were recruited from the Bangladesh CP Register (BCPR); a population-based surveillance of children and adolescents with CP in rural Bangladesh. RESULTS: Participants were 45 women including 12 female adolescents with CP and 33 female caregivers. Participants reported a wide range of experiences and needs; menarche acted as a gateway to menstrual information although for some a discourse of silence prevailed due to exclusion from peer and familial networks. Menstruation was discursively constructed as a sign of 'female maturation' marked by an expectation of 'independence', required for acceptance into socially valued adult roles, and was positioned alongside increased vulnerability to sexual abuse. Young adolescent women with CP were expected to 'quietly endure' the material aspects of menstruation although unmanaged pain and distress were described. Mothers reported an imperative for meeting their adolescent's menstrual needs however this role was discursively positioned as 'painful', 'irritating' and 'shameful', in part due to an absence of affordable, functional menstrual resources. CONCLUSION: The findings of the present study provide motivation for disability services in Bangladesh to account for the menstrual needs of young adolescent women with CP within service delivery through strategies such as providing menstrual education and by embedding value in constructs such as 'interdependence'. Moreover, interventions focused on alleviating menstrual pain among young adolescent women with CP as well as those targeted to alleviate distress among mothers providing menstrual care are required. Finally, policy responses are required to ensure that 'inclusive development' considers the needs of menstruating women with disability.

Immunisation Status of Children with Cerebral Palsy in Rural Bangladesh: Results from the Bangladesh Cerebral Palsy Register (BCPR).

BACKGROUND: Cerebral palsy (CP) is the most common cause of physical disability in childhood, with an estimated 17 million cases worldwide. There is limited data concerning the general health of this population and the immunisation status of children with CP is largely unknown. OBJECTIVE: We aimed to assess the immunisation status of children with CP in rural Bangladesh and determine the predictors of non-immunisation. METHODS: This study is part of the Bangladesh CP Register (BCPR) study; a population based CP register commenced in January 2015 in the Shahjadpur sub-district of Bangladesh. As part of BCPR registration, all children with CP in the catchment area were assessed by a paediatrician and their clinical and immunisation history were collected. RESULTS: Between January and December 2015, 615 children with CP were registered on the BCPR. The median age of the children was 7.5 years, and 38.5% were female. 91.7% of those children had a BCG vaccine scar (as an objective marker for immunisation at birth). However, only 43.2% reported to have received the rubella vaccine during the 2014 national rubella immunisation campaign. Timing of CP diagnosis was found to be an independent predictor for immunisation uptake; those diagnosed before the age of 3 were more likely to have received the rubella vaccine (95% confidence interval [CI] 1.6 - 4.3, odds ratio [OR] 2.6, p <0.0001). CONCLUSIONS: To the best of our knowledge, this is the first paper to use a formal CP register to examine the relationship between CP and immunisation status in a low or middle income country like Bangladesh. Our data suggest that more than half of children with CP in rural Bangladesh did not receive immunisation during a recent national campaign.

Needs and stressors of parents of term and near-term infants in the NICU: A systematic review with best practice guidelines.

Having a sick infant in the NICU can be quite stressful and overwhelming to parents. They require support and may have varied needs. A systematic review of qualitative and quantitative studies from 5 electronic databases (Ovid Medline, EMBASE, PsycINFO, CINAHL and Sociological Abstracts), covering January 2001 - March 2016 identified the needs and stressors of parents of term or near-term Infants in the NICU. Six articles addressed the needs and 14 identified the stressors of parents. Parents' most important need was for accurate and honest information. Needs focused around sensitive infant care and involvement in decision-making. The greatest stressor for parents was alteration to the parental role, followed by infant appearance. Fathers and parents of infants undergoing surgery are an under-researched population. Based on the evidence, enhancing staff-parent communication would better meet parental needs and reduce stressors. Our key recommendations highlight the need for family-centred and individualised care practices in the NICU.

Bacterial Dispersers along Preferential Flow Paths of a Clay Till Depth Profile.

This study assessed the dispersal of five bacterial communities from contrasting compartments along a fractured clay till depth profile comprising plow layer soil, preferential flow paths (biopores and the tectonic fractures below), and matrix sediments, down to 350 cm below the surface. A recently developed expansion of the porous surface model (PSM) was used to capture bacterial communities dispersing under controlled hydration conditions on a soil-like surface. All five communities contained bacteria capable of active dispersal under relatively low hydration conditions (-3.1 kPa). Further testing of the plow layer community revealed active dispersal even at matric potentials of -6.3 to -8.4 kPa, previously thought to be too dry for dispersal on the PSM. Using 16S rRNA gene amplicon sequencing, the dispersing communities were found to be less diverse than their corresponding total communities. The dominant dispersers in most compartments belonged to the genus Pseudomonas and, in the plow layer soil, to Rahnella as well. An exception to this was the dispersing community in the matrix at 350 cm below the surface, which was dominated by Pantoea Hydrologically connected compartments shared proportionally more dispersing than nondispersing amplicon sequence variants (ASVs), suggesting that active dispersal is important for colonizing these compartments. These results highlight the importance of including soil profile heterogeneity when assessing the role of active dispersal and contribute to discerning the importance of active dispersal in the soil environment.IMPORTANCE The ability to disperse is considered essential for soil bacteria colonization and survival, yet very little is known about the dispersal ability of communities from different heterogeneous soil compartments. Important factors for dispersal are the thickness and connectivity of the liquid film between soil particles. The present results from a fractured clay till depth profile suggest that dispersal ability is common in various soil compartments and that most are dominated by a few dispersing taxa. Importantly, an increase in shared dispersers among the preferential flow paths of the clay till suggests that active dispersal plays a role in the successful colonization of these habitats.

Novel Method Reveals a Narrow Phylogenetic Distribution of Bacterial Dispersers in Environmental Communities Exposed to Low-Hydration Conditions.

In this study, we developed a method that provides profiles of community-level surface dispersal from environmental samples under controlled hydration conditions and enables us to isolate and uncover the diversity of the fastest bacterial dispersers. The method expands on the porous surface model (PSM), previously used to monitor the dispersal of individual bacterial strains in liquid films at the surface of a porous ceramic disc. The novel procedure targets complex communities and captures the dispersed bacteria on a solid medium for growth and detection. The method was first validated by distinguishing motile Pseudomonas putida and Flavobacterium johnsoniae strains from their nonmotile mutants. Applying the method to soil and lake water bacterial communities showed that community-scale dispersal declined as conditions became drier. However, for both communities, dispersal was detected even under low-hydration conditions (matric potential, -3.1 kPa) previously proven too dry for P. putida strain KT2440 motility. We were then able to specifically recover and characterize the fastest dispersers from the inoculated communities. For both soil and lake samples, 16S rRNA gene amplicon sequencing revealed that the fastest dispersers were substantially less diverse than the total communities. The dispersing fraction of the soil microbial community was dominated by Pseudomonas species cells, which increased in abundance under low-hydration conditions, while the dispersing fraction of the lake community was dominated by Aeromonas species cells and, under wet conditions (-0.5 kPa), also by Exiguobacterium species cells. The results gained in this study bring us a step closer to assessing the dispersal ability within complex communities under environmentally relevant conditions.IMPORTANCE Dispersal is a key process of bacterial community assembly, and yet, very few attempts have been made to assess bacterial dispersal at the community level, as the focus has previously been on pure-culture studies. A crucial factor for dispersal in habitats where hydration conditions vary, such as soils, is the thickness of the liquid films surrounding solid surfaces, but little is known about how the ability to disperse in such films varies within bacterial communities. Therefore, we developed a method to profile community dispersal and identify fast dispersers on a rough surface resembling soil surfaces. Our results suggest that within the motile fraction of a bacterial community, only a minority of the bacterial types are able to disperse in the thinnest liquid films. During dry periods, these efficient dispersers can gain a significant fitness advantage through their ability to colonize new habitats ahead of the rest of the community.

Funding for cerebral palsy research in Australia, 2000-2015: an observational study.

OBJECTIVES: To examine the funding for cerebral palsy (CP) research in Australia, as compared with the National Institutes of Health (NIH). DESIGN: Observational study. SETTING: For Australia, philanthropic funding from Cerebral Palsy Alliance Research Foundation (CPARF) (2005-2015) was compared with National Health and Medical Research Council (NHMRC, 2000-2015) and Australian Research Council (ARC, 2004-2015) and CPARF and NHMRC funding were compared with NIH funding (USA). PARTICIPANTS: Cerebral Palsy researchers funded by CPARF, NHMRC or NIH. RESULTS: Over 10 years, total CPARF philanthropic funding was $21.9 million, including people, infrastructure, strategic and project support. As competitive grants, CPARF funded $11.1 million, NHMRC funded $53.5 million and Australian Research Council funded $1.5 million. CPARF, NHMRC and NIH funding has increased in real terms, but only the NIH statistically significantly increased in real terms (mean annual increase US$4.9 million per year, 95% CI 3.6 to 6.2, p<0.001). The NHMRC budget allocated to CP research remained steady over time at 0.5%. A network analysis indicated the relatively small number of CP researchers in Australia is mostly connected through CPARF or NHMRC funding. CONCLUSIONS: Funding for CP research from the Australian government schemes has stabilised and CP researchers rely on philanthropic funding to fill this gap. In comparison, the NIH is funding a larger number of CP researchers and their funding pattern is consistently increasing.

Stress and distress in parents of neonates admitted to the neonatal intensive care unit for cardiac surgery.

BACKGROUND: Parents of infants admitted to the Neonatal Intensive Care Unit (NICU) are at risk of psychological distress and NICU-related stress. However, parents of infants admitted to NICU for cardiac surgery are an under-researched population. AIMS: Identify levels of NICU-related stress, and levels of psychological distress, reported by parents of infants admitted to the NICU for cardiac surgery. STUDY DESIGN: Observational study. SUBJECTS: 69 parents of infants admitted to the NICU for cardiac surgery (cardiac group) and 142 parents of healthy infants (control group). OUTCOME MEASURES: Questionnaire packs provided to parents prior to discharge (time-point 1), and at six and 12months corrected age included: Hospital Anxiety and Depression Scale, Coping Inventory for Stressful Situations, and Family Support Scale. The Parental Stressor Scale:NICU was administered to the cardiac group at time-point 1. RESULTS: The cardiac group reported (i) that parental role alteration was the most stressful aspect of the NICU and (ii) higher scores for anxiety and depression than the control group at all three time-points, with the highest levels reported during the NICU stay. Correlation analyses indicated (i) stress associated with the sights and sounds of the NICU, and the appearance and behaviour of the infant in the NICU, had a significant positive association with anxiety and depression, and (ii) a significant negative relationship between anxiety and task-focused coping. CONCLUSIONS: An individualised parent-targeted intervention aimed at reducing stress associated with the NICU and enhancing task-focused coping style may help to reduce levels of anxiety and depression within this group of parents.

Right-sided congenital diaphragmatic hernia: A tertiary centre's experience over 25 years.

AIMS: To provide analysis on infants treated for right-sided congenital diaphragmatic hernia (RCDH) including mortality, neonatal morbidities, and associated congenital anomalies. METHODS: We reviewed records of infants admitted with RCDH from 1985 to 2010. RESULTS: A total of 160 infants with CDH were identified; of them 22 infants had RCDH, 14 (64%) were male and eight (36%) were female. Eleven of the 22 infants died (50%), of which seven (64%) were male, and four (36%) were female. Three infants (13.6%) were diagnosed prenatally, and 19 (86.4%) were diagnosed postnatally. A statistically significant association with mortality was observed for low five minute Apgar score (OR = 8; 95% CI: 1.24-51.5), and high alveolar-arterial gradient >400 (OR = 25.7; 95% CI: 2.2-298.5). Fourteen infants (64%) underwent surgical correction, three (21.4%) infants who underwent surgery died. Three infants were discharged with oxygen supplementation and tube feeding at home, and one on sildenafil. No statistical significance was observed between other variables and mortality/morbidity. We observed a change in practice in relation to timing of surgery allowing stabilisation of patient prior to surgery. Average in-patient stay for RCDH infants was 23.5 days (range: 0-112), compared with the total in-patient mean stay of 10.5 days. CONCLUSIONS: Low five minute Apgar score, and high alveolar-arterial gradient were significant predictors of mortality. RCDH is associated with high mortality (50%), prolonged length of stay and other anomalies. In recent years, we observed an improving trend for survival.

Airway, feeding and growth in infants with Robin sequence and sleep apnoea.

OBJECTIVE: Robin sequence (RS) is associated with airway abnormalities that result in functional problems of obstructive sleep apnoea (OSA), feeding difficulties, and consequent poor growth. We evaluated the relationships between OSA severity, airway and feeding interventions, and weight at 12 months in infants with RS and OSA. METHODS: Retrospective notes review of children with RS managed at our neonatal unit (1998-2010, inclusive). RESULTS: Of 39 infants studied, 10 (25.6%) had mild/moderate OSA, and 29 (74.4%) severe. Infants with severe OSA required more airway interventions in hospital (82.8 vs 30.0%, p = 0.004) and at discharge (72.4 vs 20.0%, p = 0.007) than those with mild/moderate OSA; 30.0% of infants with mild/moderate OSA required continuous positive airway pressure (CPAP) during admission and 20.0% on discharge, but amongst those with severe OSA 82.8% required airway interventions as an inpatient, 17.2% underwent mandibular distraction osteogenesis, and 55.2% required CPAP on discharge. Those with severe OSA were also more likely to require tube feeding on discharge (89.7 vs 50.0%, p = 0.02). Overall, children were on a lower weight centiles at discharge compared to birth (-10.2 centiles) and at 12 months of age compared to birth (-14.8 centiles), but this occurred irrespective of OSA severity or need for airway interventions or tube feeding. CONCLUSIONS: Infants with RS commonly have OSA, feeding and airway difficulties. Weight at 12 months appeared not to be influenced by OSA severity, feeding or airway problems, suggesting that current intervention/management strategy results in the severely affected infants growing as well as those affected less severely.

Healing patterns of critical size bony defects in rats after grafting with bone substitutes soaked in recombinant human bone morphogenetic protein-2: histological and histometric evaluation.

The aim of the study was to evaluate the effect of different bone substitutes soaked in recombinant human bone morphogenetic protein-2 (rhBMP-2) on the healing of critical size defects in calvarial bone. Defects were created in 24 Sprague Dawley rats. The rhBMP-2 was diluted to obtain a final concentration of 0.2mg/ml. Rats were divided into four groups and treated as follows: in the first group the defect was filled with anorganic bovine bone mineral (ABBM) and rhBMP-2, the second group was treated with freeze-dried bone allograft (FDBA) and rhBMP-2, and the third group was treated with autogenous bone (AUTO). In the control group the defects were left untreated. Animals were killed after 8weeks and calcified histological sections prepared. Histometric measurements showed that mean (SD) bone formation was 4.00 (1.69)mm(2) in the ABBM group, 2.56 (1.06)mm(2) in the FDBA group, and 2.30 (0.34)mm(2) in the AUTO group. The difference between the ABBM group and the other 3 groups was significant (p<0.0001) with a mean bone formation of 0.82 (0.25)mm(2) in the control group. There was no significant difference between the FDBA and the AUTO groups (p=0.96). Within the limits of this study we concluded that the addition of rhBMP-2 to bone substitutes was efficacious in regenerating bone in critical size bone defects in calveria in rats.

Plasma levels of adrenomedullin and atrial natriuretic peptide in patients with congestive heart failure of various etiologies.

OBJECTIVE: The aim of this study was to evaluate the plasma levels of the adrenomedullin (ADM) and atrial natriuretic peptide (ANP) in adult and pediatric patients with congestive heart failure (CHF) of various etiologies and to investigate their relations with haemodynamic variables e.g. echocardiographic left ventricular ejection fraction (LVEF) and fractional shortening (FS). SUBJECTS AND METHODS: The study was made in 38 adult and 21 pediatric patients with CHF of various etiologies and compared with 15 adult and 10 pediatric normal healthy controls. Patients with CHF were classified according to the New York Heart Association (NYHA) functional classification into grades II to IV in adult patients and into grade IV in all pediatric patients. ADM and ANP plasma levels were determined prior to the treatment with enzyme immunoassay. RESULTS: A statistically significant difference in the plasma levels of ADM and ANP were found between pediatrics and adult patients and corresponding healthy controls. Their levels were progressively increased with severity of NYHA class in adult patients. We found a significant positive correlation between plasma levels of each of ADM and ANP and pulse rate, systolic and diastolic blood pressure; and a significant negative correlation between their plasma levels and echocardiographic LVEF and FS. A significant positive correlation between plasma levels of ADM and ANP in both pediatrics and adult patients were also found. CONCLUSION: Plasma levels of ADM and ANP increased in adult and pediatric patients with CHF irrespective of the cause. They were positively correlated with each other and negatively correlated with LVEF and FS. These findings might have important clinical implications in that a noninvasive blood test may be used to identify high-risk subjects for HF for more invasive procedures.

Thyroid hormone supplementation for the prevention of morbidity and mortality in infants undergoing cardiac surgery.

BACKGROUND: Paediatric studies have demonstrated that cardiopulmonary bypass is associated with a decline in thyroid hormone levels. Adult patients who undergo open heart surgery and receive triiodothyronine supplementation have demonstrated a dose-dependent increase in cardiac output which has been associated with an improved clinical outcome. Thyroid hormone supplementation in infants may also reduce post-operative morbidity and mortality. OBJECTIVES: To determine if peri-operative thyroid hormone supplementation or replacement in infants undergoing cardiac surgery on cardiopulmonary bypass improves post-operative and longer term morbidity and mortality. SEARCH STRATEGY: The standard search strategy of the Cochrane Neonatal Review Group was used. This included searches of The Oxford Database of Perinatal Trials, MEDLINE (1966 - December 2003), EMBASE (1980 - December 2003), CINAHL (1982 - December 2003), The Cochrane Central Register of Controlled Trials (The Cochrane Library, Issue 2, 2003), previous reviews including cross references, abstracts, conferences, symposia proceedings, expert informants and journal handsearching in the English language. SELECTION CRITERIA: All trials using random allocation to peri-operative thyroid hormone therapy (supplementation or replacement) compared to control (placebo or no therapy) in infants (birth to one year of age) undergoing cardiac surgery requiring cardiopulmonary bypass. Thyroid hormone therapy must be tri-iodothyronine. DATA COLLECTION AND ANALYSIS: Primary clinical outcomes included measures of post-operative morbidity and mortality. The standard methods of the Cochrane Neonatal Review Group were used in the assessment of trial quality. Treatment effects were expressed using relative risk (RR) and mean difference (MD). MAIN RESULTS: Two very small studies were identified that tested peri-operative thyroid hormone supplementation or replacement in infants aged less than one year undergoing cardiac surgery (Chowdhury 2001; Portman 2000). In the Chowdhury 2001 study, a subgroup of nine neonates was eligible for this review. No deaths occurred during either study. Chowdhury 2001 found no significant effect of peri-operative thyroid hormone supplementation in neonates on either length of hospital stay or duration of mechanical ventilation. Portman 2000 found no significant difference in dopamine requirements for the treatment versus control groups for the first 24 hours post operatively, while in the Chowdhury neonatal subgroup, inotrope requirements were significantly lower in the treatment group. Portman 2000 reported significant differences between the two groups at 1 and 24 hours post operatively for free T3 and at 1 hour post operatively for total T3 levels. Total T4 levels showed no significant difference between groups, either pre-cardiopulmonary bypass or up to 72 hours post operatively. REVIEWERS' CONCLUSIONS: At present, there is a lack of evidence concerning the effects of tri-iodothyronine supplementation in infants undergoing cardiac surgery. Further randomised controlled trials which include sufficiently large subject numbers in a variety of different age strata (neonates, infants and older children) need to be undertaken.

Regional (spinal, epidural, caudal) versus general anaesthesia in preterm infants undergoing inguinal herniorrhaphy in early infancy.

BACKGROUND: With improvements in neonatal intensive care, more premature infants are surviving the neonatal period. With this increase, more are presenting for surgery in early infancy. Of predominance in this period is the repair of inguinal herniae, appearing in 38% of infants whose birth weight is between 751g and 1000g. Most postoperative studies show that approximately 20% to 30% of otherwise healthy former preterm infants having inguinal herniorrhaphy under general anaesthesia have one or more apnoeas in the postoperative period. Regional anaesthesia might reduce postoperative apnoea in this population. OBJECTIVES: To determine if regional anaesthesia, in preterm infants undergoing inguinal herniorrhaphy, reduces post-operative apnoea, bradycardia, and the use of assisted ventilation, in comparison to those infants undergoing inguinal herniorrhaphy with general anaesthesia. SEARCH STRATEGY: Randomised controlled trials were identified by searching MEDLINE (1966-Nov 2002), EMBASE (1982-Nov 2002), Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 1, 2002), reference lists of published trials and abstracts published in Pediatric Research. SELECTION CRITERIA: Randomised and quasi-randomised controlled trials of spinal versus general anaesthesia in preterm infants undergoing inguinal herniorrhaphy in early infancy. DATA COLLECTION AND ANALYSIS: Data were extracted and the analyses performed independently by two reviewers. Authors of each eligible study were contacted for missing data. Studies were analysed for methodologic quality using the criteria of the Cochrane Neonatal Review Group. All data were analysed using RevMan 4.1. When possible meta-analysis was performed to calculate typical relative risk, typical risk difference, along with their 95% confidence intervals (CI). MAIN RESULTS: Four small trials comparing spinal with general anaesthesia in the repair of inguinal hernia were identified. One trial was excluded due to inadequate information. There was no statistically significant difference in the proportions of infants having postoperative apnoea/bradycardia, typical RR 0.69 (0.40, 1.21) or postoperative oxygen desaturations, RR 0.91 (0.61, 1.37). If infants having preoperative sedatives were excluded, then the meta-analysis supported a reduction in postoperative apnoea in the spinal anaesthetic group, typical RR 0.39 (0.19, 0.81). There was a reduction of borderline statistical significance in the use of postoperative assisted ventilation with spinal anaesthesia. There was an increase of borderline statistical significance in anaesthetic placement failure when spinal anaesthesia was attempted. REVIEWER'S CONCLUSIONS: There is no reliable evidence from the trials reviewed concerning the effect of spinal as compared to general anaesthesia on the incidence of post-operative apnoea, bradycardia, or oxygen desaturation in ex-preterm infants undergoing herniorrhaphy. The estimates of effect in this review are based on a total population of only 108 patients or fewer.A large well designed randomised controlled trial is needed to determine if spinal anaesthesia reduces post-operative apnoea in ex-preterm infants not pretreated with sedatives. Adequate blinding, follow up and intention to treat analysis are required.

Gastroschisis: determinants of neonatal outcome.

This retrospective study elicits information regarding the dependence of neonatal outcome in gastroschisis upon: (1) the mode of delivery, (2) place of birth, (3) time for birth to surgery, (4) method of closure, (5) time from operation to commencement of first enteral feeds. The neonatal intensive care database from five major tertiary centres was used to identify 181 neonates with gastroschisis from 1990 to 2000. There were 8 deaths. There were no significant differences in outcome for infants delivered vaginally (102) versus Caesarean section (79), those born near the tertiary centre (133) as compared to infants born away (48), ones operated within 7 hours (125) compared with those operated after 7 hours (56), with delayed closure (30) versus primary closure (151). Neonates fed within 10 days of operation (85) had significantly lower incidence of sepsis, duration of TPN and hospital stay when compared to those fed after 10 days (96). Early commencement of feeds decreases the incidence of sepsis, duration of total parenteral nutrition (TPN) and hospital stay. Place of delivery, mode of delivery, time to surgery and type of closure do not influence neonatal outcome.

Pre-eclampsia: a predisposing factor for neonatal venous sinus thrombosis?

Neonatal venous sinus thrombosis is a well-recognized, but infrequently diagnosed, cause of neonatal encephalopathy. Previous reports have tended to omit reference to the importance of maternal factors in predisposing the infant to this condition. This report, in which eight patients with neonatal venous sinus thrombosis are presented, will reveal a strong association between pre-eclampsia, prothrombotic disorders, and neonatal venous sinus thrombosis. Contrary to previously published reports, there is a high likelihood of neurodevelopmental residua after this condition.

Life expectancy among people with cerebral palsy in Western Australia.

This report describes trends, predictors, and causes of mortality in persons with cerebral palsy (CP) using individuals identified by the Western Australian Cerebral Palsy Register and born between 1958 and 1994. Two thousand and fourteen people were identified (1154 males, 860 females), of whom 225 had died by 1 June 1997. Using date-of-death data, crude and standardized mortality rates were estimated and predictors of mortality sought using survival analysis stratified by decade of birth, description of impairments, and demographic and perinatal variables. For those born after 1967, the cause of death profile was examined over time. Mortality exceeded 1% per annum in the first 5 years and declined to age 15 years after which it remained steady at about 0.35% for the next 20 years. The strongest single predictor was intellectual disability, but all forms of disability contributed to decreased life expectancy. Half of those with IQ/DQ score <20 survived to adulthood, increasing to 76% with IQ/DQ score 20-34, and exceeding 92% for higher scores. Severe motor impairment primarily increased the risk of early mortality. Despite there being 72 persons aged from 25 to 41 years with severe motor impairment in our data set, none had died after the age of 25 years. Infants born after more than 32 weeks' gestation were at significantly higher risk of mortality than very preterm infants, accounted for by their higher rates of intellectual disability. No improvements in survival of persons with CP were seen over the study period despite advances in medical care, improved community awareness, and the increasing proportion of very preterm births among people with CP. This may be the result of improved neonatal care enabling the survival of infants with increasingly severe disabilities.