Risk factors for adverse outcomes of bacterial meningitis.

OBJECTIVE: To identify risk factors for adverse outcomes from bacterial meningitis. METHODOLOGY: From a cohort of 166 children with bacterial meningitis who were studied prospectively, 130/158 (82%) survivors underwent neurological, neuropsychological, audiological and behaviour assessments 5-9 years following their illness. RESULTS: Major adverse outcomes included B/166 (4.8%) deaths and severe neurological, intellectual or audiological sequelae in 11/130 (8.5%) children followed. Another 24 (18.5%) had cognitive, auditory or behaviour disorders. Bivariate analysis found age < or = 12 months, tertiary referral, symptoms > 24 h before diagnosis, seizures, focal neurological signs, deteriorating conscious state in hospital, Streptococcus pneumoniae infection and serum sodium concentration < 130 mmol/L were associated with adverse outcomes. Multivariate analysis showed age < or = 12 months, symptoms > 24 h, seizures after 72 h in hospital and focal neurological signs as independent risk factors. These were present in 18/19 (95%) children with major sequelae, but absent in 9/24 (37.5%) children with minor disabilities. CONCLUSIONS: As minor disabilities following meningitis cannot be predicted, all survivors require assessment during their early school years.

Adverse outcomes of bacterial meningitis in school-age survivors.

OBJECTIVE: To determine the outcomes of bacterial meningitis in school-age survivors. DESIGN: Prospective cohort study. SETTING: Teaching pediatric hospital. CHILDREN: During 1983 through 1986, 158 meningitis survivors, ages 3 months to 14 years, treated at a single center were enrolled. Between 1991 and 1993, 130 children, 82% of the original cohort, were evaluated at a mean age of 8.4 years and a mean of 6.7 years after their meningitis. OUTCOME MEASURES: Blinded neurologic, neuropsychologic, audiologic, behavior, and socio-demographic assessments were compared with those from grade- and sex-matched control children. Multivariate analyses adjusted for age at testing and socio-demographic variables. RESULTS: There was a systematic increase in risk of abnormality or poorer functioning for children with meningitis, compared with control children, across all categories tested, which was significant for fine motor function, Intelligence quotient (IQ) scores, and tests of school behavior, neuropsychologic function, and auditory figure-ground differentiation. Eleven children who had experienced meningitis (8.5%) had major deficits (IQ < 70, seizures, hydrocephalus, spasticity, blindness, or severe to profound hearing loss); a further 24 (18.5%) cases and 14 (10.8%) control children had minor deficits (IQ 70 to 80, inability to read, mild to moderate hearing loss, abnormalities in speech discrimination, or school behavior problems). Overall, children who had meningitis were at greater risk (26.9%) for disability. Children with acute neurologic complications had more adverse outcomes than those with uncomplicated meningitis and control children (39% vs 18% vs 11%, respectively). CONCLUSIONS: One in four school-age meningitis survivors has either serious and disabling sequelae or a functionally important behavior disorder, neuropsychologic or auditory dysfunction adversely affecting academic performance. As a group, survivors function less well than their classroom peers, and risk is greatest for, but not confined to, those who had acute neurologic complications. All survivors require careful follow-up, at least until school age.

The association of thyroid dyshormonogenesis and deafness (Pendred syndrome): experience of the Victorian Neonatal Thyroid Screening Programme.

Between 1977 and 1989, the Victorian Neonatal Thyroid Screening Programme detected five subjects with thyroid dyshormonogenesis and sensorineural deafness. These patients have been diagnosed as having Pendred syndrome. In two of the children, thyroid function tests which were initially abnormal at birth returned to normal spontaneously without treatment. However, hypothyroidism subsequently recurred and the children required thyroxine therapy. These two children could have been mistakenly diagnosed as having transient hypothyroidism. The detection of five patients with Pendred syndrome illustrates the importance of audiological assessment in all babies with thyroid dyshormonogenesis in whom there is increased uptake of isotope on thyroid scanning. In our experience, hearing loss in patients with Pendred syndrome may be progressive over time, so that repeated audiological assessments are necessary.

Changing outcome over 13 years of very low birthweight infants.

The survival prospects for infants of birthweight less than or equal to 1500 g born in recent years have improved. Evidence for a corresponding decrease in long-term morbidity of survivors is conflicting but recent reports from some centers indicate that high morbidity rates are occurring. Until additional satisfactory reports are available on the outcome of very low birthweight (VLBW) infants born after 1975, preferably from a community or region, uncertainty will continue. The outcome of three cohorts of VLBW infants, born in the Royal Women's Hospital, Melbourne between 1966 and 1978 is reported; more than 90% of each cohort were fully assessed, aged 2-8 years. There were 169 long-term survivors from the first cohort (1966-1970 births) and 72 from the second cohort (1973-74 births); survival rates were 37.1% and 37.3% respectively; however, for the 1977-78 births, there were 161 survivors, a significant increase to 68.3%. In the first cohort, 32.7% had one or more visual defects and 3.9% were blind but visual morbidity decreased progressively in cohorts 2 and 3; 3% of the second cohort and 1.2% of the third cohort were blind. There was a trend for a decrease in severe sensorineural deafness. Cerebral palsy increased progressively, respectively 2.6%, 4.5% and 11.9% in the first, second and third cohorts. There was a significant increase in the mean Mental Developmental Index of the Bayley Scales at the age of 2 years from 75.38 for the 64 children born in 1966-70 compared with 90.96 for 150 children in the 1977-78 cohort. Although there had been an increase in upper social class families in the more recent cohort, improvement in test scores was still highly significant when higher social classes (1-3 Congalton Scale) were excluded. However, there was no significant improvement in the 6 year psychological test scores of the first and second cohorts. There was a steady increase in occurrence of cerebral palsy. Significance associations in the 1977-78 cohort were found with only 2 perinatal variables (use of theophylline and necrotizing entercolitis). Furthermore, 17 (89.5%) of children had a five-minute Apgar score greater than 5 and 14 (73.7%) did not require ventilatory support: Prevention of cerebral palsy by selective treatment in the delivery room or nursery was not feasible for prediction of this condition was not possible from perinatal risk factors.

A longitudinal study of very low-birthweight infants. IV: An overview of performance at eight years of age.

A cohort of 169 very low-birthweight infants (800 to 1500g) was followed prospectively to the age of eight years. Information on 159 of the children was available at that age, and for a further five to the age of six years. A comparison group of 67 normal-birthweight children was also followed, but only 43 of these children were seen at the age of eight years. Eight of the very low-birthweight (VLBW) children were attending special schools and 156 attended normal schools: placement of the remaining five was unknown. Of the VLBW children who were adequately assessed, 15.9 per cent were either not reading or were retarded by more than 18 months. Mean VLBW full-scale IQ was 88.8, compared with 98.8 for the normal-birthweight group. A subgroup of 10 VLBW children with birthweights under 1000g had lower mean scores on all three WISC-R scales compared with those with birthweights between 1000 and 1500g. Of the adequately assessed VLBW children, 3.7 per cent had epilepsy, 3.7 per cent had significant sensorineural deafness and 2.4 per cent suffered from cerebral palsy. One or more visual defects were detected in 31.4 per cent of the children, though in only 3.8 per cent was the defect serious. At eight years, growth dimensions for the VLBW children were below the 10th percentile for 11.0 per cent in weight, 16.1 per cent in height and 15.0 per cent in head circumference. Degrees of handicap in the VLBW children were profound in 5.1 per cent, severe in 10.8 per cent and significant in 40.5 per cent: handicap was minimal or absent in the remaining 43.6 per cent. For the normal-birthweight group the percentages were 2.3, 0, 25.6 and 72.1 respectively. The VLBW children with minimal or no handicap were considered to have a satisfactory outcome. This was significantly correlated with the following: gestation over 30 weeks; birthweight over 1199g; no major apnoeic attacks; lowest postnatal weight before six days; return to birth weight before 21 days; peak serum bilirubin not exceeding 255 mumol/litre; and parental social-class between 2 and 5 on the seven-point Congalton Scale.

A longitudinal study of very low-birthweight infants. II: Results of controlled trial of intensive care and incidence of handicaps.

Between 1966 and 1970, infants with birthweights between 1000 and 1500g entered a randomized controlled trial to determine the short-term and long-term results of neonatal intensive care. Of 158 long-term survivors, five were lost to follow-up, but the multidisciplinary research team prospectively followed 143 children up to the age of eight years. Useful data were available for the other 10 children. Of the long-term survivors 74 had received routine, and 84 had received intensive nursery care. At eight years of age there were no statistically significant differences in the frequencies of a variety of individual abnormalities; fewer of the intensively managed children had cerebral palsy, but sensorineural deafness and ocular abnormalities occurred more frequently. Individual children were graded into four carefully defined groups: (a) profound handicap (4.4 per cent of entire study group); (b) severe handicap (10.1 per cent); (c) significant handicap (37.3 per cent); and (d) trivial or no handicap (41.8 per cent). Inadequate data were available for 6.3 per cent of the children. It was apparent that the improved survival attributed to intensive neonatal care was achieved at the expense of additional severely handicapped children, and this feature is discussed.