Neurodevelopmental and functional outcomes of extremely low birth weight infants in the National Institute of Child Health and Human Development Neonatal Research Network, 1993-1994.

OBJECTIVES: The purposes of this study were to report the neurodevelopmental, neurosensory, and functional outcomes of 1151 extremely low birth weight (401-1000 g) survivors cared for in the 12 participating centers of the National Institute of Child Health and Human Development Neonatal Research Network, and to identify medical, social, and environmental factors associated with these outcomes. STUDY DESIGN: A multicenter cohort study in which surviving extremely low birth weight infants born in 1993 and 1994 underwent neurodevelopmental, neurosensory, and functional assessment at 18 to 22 months' corrected age. Data regarding pregnancy and neonatal outcome were collected prospectively. Socioeconomic status and a detailed interim medical history were obtained at the time of the assessment. Logistic regression models were used to identify maternal and neonatal risk factors for poor neurodevelopmental outcome. RESULTS: Of the 1480 infants alive at 18 months of age, 1151 (78%) were evaluated. Study characteristics included a mean birth weight of 796 +/- 135 g, mean gestation (best obstetric dates) 26 +/- 2 weeks, and 47% male. Birth weight distributions of infants included 15 infants at 401 to 500 g; 94 at 501 to 600 g; 208 at 601 to 700 g; 237 at 701 to 800 g; 290 at 801 to 900 g; and 307 at 901 to 1000 g. Twenty-five percent of the children had an abnormal neurologic examination, 37% had a Bayley II Mental Developmental Index <70, 29% had a Psychomotor Developmental Index <70, 9% had vision impairment, and 11% had hearing impairment. Neurologic, developmental, neurosensory, and functional morbidities increased with decreasing birth weight. Factors significantly associated with increased neurodevelopmental morbidity included chronic lung disease, grades 3 to 4 intraventricular hemorrhage/periventricular leukomalacia, steroids for chronic lung disease, necrotizing enterocolitis, and male gender. Factors significantly associated with decreased morbidity included increased birth weight, female gender, higher maternal education, and white race. CONCLUSION: ELBW infants are at significant risk of neurologic abnormalities, developmental delays, and functional delays at 18 to 22 months' corrected age.

Long-term neurodevelopmental outcome of asphyxiated newborns.

Perinatal asphyxia associated with hypoxic-ischemic brain injury remains an important cause of long-term morbidity in both premature and term infants. Early, severe neurologic dysfunction appears to be the most useful indicator that a significant hypoxic-ischemic insult has occurred, and is the best predictor of neurologic sequelae. There are distinct gestational age dependent differences in the vulnerability of specific cerebral structures to hypoxic-ischemic damage, which ultimately determines the type and severity of neurologic sequelae. Both major and minor handicapping conditions are seen, the latter having important consequences on later academic achievement. Long-term, longitudinal follow-up is required for any asphyxiated infant with early intervention as the goal. As newer imaging modalities are employed and studied, we are learning more about the neuropathology of asphyxia and correlating it to outcome. However, the ability to accurately predict long-term neurodevelopmental outcome in seriously asphyxiated infants remains elusive.

Follow-up for infants with necrotizing enterocolitis.

Following discharge from the hospital, many infants who have survived acute necrotizing enterocolitis (NEC) remain at significant risk for continuing morbidity. Follow-up care of these infants is increasingly becoming the responsibility of the primary care physician. This article reviews the more common long-term medical and neurodevelopmental sequelae identified in NEC survivors and presents a practical approach to the clinical follow-up of these infants.

Practitioner ethics and managed care.

Mental health services provided through a managed care company cause some serious ethical concerns for providers and potentially for licensing boards. Confidentiality, record keeping, abandonment of patients, and informed consent are a few of the major issues confronting providers and the patients with whom they work. The importance of these issues for providers and the need for managed care companies and their employees to pay more attention to these ethical problems are covered in this article.

Catch-up head growth and motor performance in very-low-birthweight infants.

The relationship between catch-up head growth and motor performance was examined in 48 very-low-birthweight (< 1,500 g) infants. All infants were nonasphyxiated, normocephalic, and appropriately grown for gestational age at birth. Serial cranial ultrasonography during the first month of life revealed no intracranial pathology. The age of catch-up head growth, defined as the corrected age when the head circumference recovered to the 5th percentile, was determined for each infant. At 12 months corrected age, the infants were evaluated and grouped according to normal (n = 37) or abnormal (n = 11) motor assessments. The abnormal group achieved catch-up head growth by 7.7 +/- 2.1 months vs 3.7 +/- 3.1 months for the normal group (P < .05). Only 27% of the motor-delayed infants achieved catch-up head growth by 6 months corrected age, as compared with 89% of the normal infants (P < .05). Premature infants who have achieved catch-up head growth by 6 months corrected age, corresponding to the period of maximal postnatal brain growth, have fewer motor abnormalities than infants who attain catch-up head growth later. There is a significant relationship between head circumference at 6 months corrected age and motor development in very-low-birthweight infants.

The effect of abdominal incisions on early motor development of infants with necrotizing enterocolitis.

Eighteen very low-birthweight infants with necrotizing enterocolitis (NEC) underwent periodic neurodevelopmental testing until two years of age. They were grouped according to whether they had had surgical intervention (N = 6) or non-surgical therapy (N = 12). At eight and 15 months corrected age, a significantly greater number of the surgical group exhibited motor delay. At 24 months, only one infant in the surgical group had persistent motor delays. These findings indicate a higher incidence of motor delays in infants requiring surgery for NEC. The delays involved skills influenced by the abdominal musculature. These motor delays persisted up to 24 months, but appeared to resolve with time.

Evaluation and management of stridor in the newborn.

Stridor in a newborn should necessitate an immediate work-up to rule out a life-threatening airway obstruction. Three cases of newborns with stridor are presented. These cases emphasize the need for an immediate and thorough physical examination of any stridorous newborn, followed by radiologic studies and direct laryngoscopy. While other invasive procedures are frequently required for a precise diagnosis, a careful examination with special attention to the quality of the stridor often permits a more effective diagnostic approach in an atmosphere of appropriate urgency.

Necrotizing enterocolitis in multiple-birth infants.

Over a 5-year period, 20 infants of multiple-gestation births (16 twin, 2 triplet) developed necrotizing enterocolitis (NEC) (15 infants) or suspected NEC (5 infants). During the same period, 532 infants of multiple gestations were admitted to our neonatal intensive care unit, yielding a NEC incidence in this population of 3.8%. In two twin sets, both infants developed NEC or suspected NEC, and in three sets only the affected twin was transferred to our nursery. Five infants required surgical intervention (25%) and three infants died (overall mortality, 15%). Fifteen siblings who did not develop NEC served as a control group. Analysis showed that the 1-minute Apgar score was the most significant factor in predicting NEC (P less than .028) and need for surgical intervention (P less than .020). In this series, 82% of the infants with 1-minute Apgar less than 6 developed NEC, whereas 31% with 1-minute Apgar greater than 6 developed NEC.