Neurodevelopmental outcome in very low birth weight infants at 24 months and 5 to 7 years of age: changing diagnosis

The purpose of this study was to evaluate the importance of root canal therapy in the healing process of severe intrabony defects. Four beagle dogs were used and 32 interproximal intrabony defects, up to the apical third, were created. Wire ligatures were placed into these defects for plaque accumulation. Three weeks later, the ligatures were removed and 4 different treatment modalities were employed: group 1) scaling and root planing (SRP); group 2) modified Widman flap (MWF); group 3) modified Widman flap and root canal therapy performed at the same time (RCT/MWF); and group 4) modified Widman flap and root canal therapy performed 3 weeks after the surgical procedure (MWF + RCT). Postoperative oral hygiene was obtained by spraying a 0.12% chlorhexidine solution 3 times a week. The animals were sacrificed 7 weeks after treatment. Blocks were obtained and processed for routine histology. Results were expressed as a percentage of the total defect length (TDL). No differences were observed when SRP was compared to MWF. New bone formation (BF) presented better results for SRP (43.4%) and MWF (53.4%) when compared to RCT/MWF (15.5%). New cementum formation (CF) presented better results for SRP (59.8%) and MWF (64.6%) when compared to RCT/MWF (19.3%) and MWF + RCT (31.5%). Connective tissue repair (CTR) presented better results for SRP (72.4%) and MWF (74.2%) when compared to RCT/MWF (47.5%) and MWF + RCT (44.4%). Results were statistically significant at the level of 0.05. Within the limits of this study, it was concluded that root canal therapy performed simultaneously or 3 weeks after surgery modified the healing of intrabony defects, impairing new bone formation, new cementum formation and new attachment.     

Twenty-month outcome in ventilator-dependent, very low birth weight infants born during the early years of dexamethasone therapy

We sought to examine the effect of the introduction of dexamethasone therapy on health, growth, and neurodevelopmental outcome in very low birth weight (VLBW) infants at 20 months of age. We compared outcomes in all 86 VLBW infants (mean birth weight 871 gm, mean gestational age 26.4 weeks) who were ventilator dependent on day 21 of life during the 2 years preceding October 1988 (period 1), when dexamethasone therapy became accepted clinical practice in our unit, with outcomes in all 124 infants (mean birth weight 891 gm, mean gestational age 26.9 weeks) with similar ventilator status during the subsequent 2 years (period 2). In addition, we compared outcomes in infants who received dexamethasone during period 2 with those in a concurrent cohort of less ill infants who were not given dexamethasone. There were no significant differences between periods 1 and 2 in mortality rates after 21 days (17% vs 21%), need for home oxygen (23% vs 25%), oxygen dependence at 20 months of corrected age (11% vs 10%), rate of neurosensory impairment (24% vs 25%), and mean Bayley Mental scores (81.5 vs 77.2) or Psychomotor Development Index (81.6 vs 71.1). Infants who received dexamethasone during period 2 had significantly more severe lung disease and poorer respiratory, growth, and developmental outcomes. We conclude that VLBW infants with ventilator-dependent chronic lung disease have very poor outcomes, even when treated with dexamethasone. More information is needed from prospective, randomized trials before dexamethasone can be accepted as routine therapy for chronic lung disease.     

Attachment security in very low birth weight infants.

34 infants of very low birth weight (VLBW) and a comparison group of 40 full-term infants were observed in the Strange Situation of M. D. Ainsworth et al (1978) at 14 and 19 mo and observed in the home at 14 mo of age, using E. Waters's (1995) Attachment Q-set. Results indicated that at 14 mo VLBW infants were more likely than the full-term infants to be insecurely attached when rated using the Q-set but not when using the Strange Situation. However, at 19 mo VLBW infants were also more likely than full-term infants to be insecurely attached in the Strange Situation assessment. There were no associations between the Q-set and Strange Situation measures of attachment security. These results are discussed in terms of the social-emotional development of VLBW infants. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Psychiatric sequelae of low birth weight at 6 years of age

The study examined the association between low birth weight (LBW) (< or = 2,500 g) and attention deficit hyperactivity disorder (ADHD) in two socioeconomically disparate populations. LBW and normal birth weight (NBW) children from the 1983 to 1985 newborn lists of an urban and a suburban hospital in Southeast Michigan were randomly selected. A total of 823 children, 473 LBW and 350 NBW, participated. Data were gathered in 1990 to 1992, when the children were 6 to 7 years of age. The National Institute of Mental Health Diagnostic Interview Schedule for children-Parent version (DISC-P) was used to elicit information on DSM-III-R diagnoses of simple phobia, overanxious, separation anxiety, oppositional defiant, and ADHD. Teachers' ratings of behavior problems were obtained. LBW was associated with ADHD but not with childhood anxiety disorders or oppositional defiant disorder. The association was stronger in the urban than in the suburban population. Data from teachers' ratings revealed an association between LBW and attention problems. The prognostic significance of the observed psychopathology at 6 years of age requires follow-up assessment as the children mature.     

Maternal risk factors in infants with very low birth weight

To determine whether maternal risk factors associated with the delivery of very low birth weight infants under 1501 g are different from those associated with low birth weight infants of 1501 to 2500 g, prenatal data on 12,247 deliveries were evaluated. The sample contained 302 very low birth weight infants. Maternal race, age, height, weight, gravidity, parity, past pregnancy performance, and pregnancy complications were analyzed. Factors related to very low birth weight but not to low birth weight infants were previous abortions, previous fetal deaths, and hypertensive vascular disease. Race, maternal height, and prepregnancy weight were not related to very low birth weight but were associated with an increase in low birth weight. There was no significant difference in the rate of very low birth weight or low birth weight by maternal age from 14 to 40 years. These results contradict the concept of a uniform set of predisposing factors for birth of all infants weighing 2500 g or less.     

Cerebral MRI of very low birth weight children at 6 years of age compared with the findings at 1 year

The objective was to describe a new surgical technique to manage a posteriorly dislocated crystalline lens. Four patients with posteriorly dislocated lenses were studied. Two patients had dislocated lenses secondary to trauma, 1 had undergone retinal detachment surgery, and 1 had an idiopathic lens dislocation. Pars plana vitrectomy was carried out on all 4 eyes, followed by an injection of perfluoro-n-octane to float the lens off the retina. The lens was phacoemulsified through a limbal incision, and an intraocular lens was positioned in the ciliary sulcus with suture fixation. Perfluoro-n-octane was replaced by a balanced salt solution. Postoperative visual acuity ranged from 1.0-1.5. Transient choroidal detachment and hypotony were observed in 3 eyes in the early postoperative period. Postoperative ocular hypertension was noted in 2 eyes and was well-controlled with topical antiglaucoma agent. These results indicate that limbal lensectomy of a posteriorly dislocated lens using perfluorocarbon liquids is a beneficial and relatively safe method.     

Combined effects of antenatal corticosteroids and surfactant supplementation on the outcome of very low birth weight infants

Antenatal corticosteroids in preterm pregnancy may result in the reduction of the incidence of respiratory distress syndrome (RDS) and neonatal mortality. It is well known that postnatal use of surfactant in very low birth weight (VLBW) infants with RDS results in decreased neonatal morbidity and mortality. To evaluate the additive beneficial effects of combined antenatal corticosteroids and postnatal use of rescue surfactant on the outcome of VLBW infants, we retrospectively reviewed 286 maternal/infant charts of preterm infants with gestational ages 23 to 32 weeks and birth weights 501 to 1500 gm who were born at our institution from 1991 through 1994. Of the 87 (30%) infants who were treated with corticosteroids before birth, 41 (47%) had RDS, and of the 199 (70%) infants who were not treated with corticosteroids before birth, 162 (81%) had RDS (p < 0.001). The infants who had RDS and who were treated with corticosteroids before birth had a decreased incidence of pulmonary air leaks and a decreased need for diuretic therapy. In addition, they had a significant reduction in O2 requirement and ventilator settings as reflected by FIO2, mean airway pressure, ventilator rate, O2 index, and A-aDO2 before they received the first dose of rescue surfactant (p < 0.05 to p < 0.01) in contrast to other VLBW infants who had RDS and who were not treated with corticosteroids before birth. We conclude that antenatal corticosteroid therapy in threatened premature labor combined with the use of postnatal rescue surfactant is associated with a decreased incidence of RDS and may be beneficial for reducing the severity of RDS and improving the eventual outcome of VLBW infants.     

Effect of erythromycin on feeding intolerance in very low birth weight infants: a preliminary observation

The objective of the study was to measure the change in physicians' attitudes toward preventive care guidelines over a 2-year period. The study was conducted at a Southern California managed care medical group that was experiencing intense price competition. We analyzed individualized survey responses of 62 HMO primary care physicians over the study period. We found that physicians increasingly believed that clinical guidelines were being used for cost containment (first survey 71% vs second survey 92%, p < .005) and less for quality improvement (first survey 85% vs second survey 67%, p < .008) over time. These findings may create a barrier to physicians' adoption of practice guidelines.     

Developmental versus conventional care: a comparison of clinical outcomes for very low birth weight infants

The purpose of this research was to describe the clinical profile of very low birth weight (VLBW) infants receiving conventional versus developmental care during their hospitalization and to determine the appropriateness of developmental-care interventions. A phase-lag study with 124 preterm infants indicated that although there were no significant differences in individual clinical outcomes, developmental care had a significant effect on the physiologic stability of the infant over time. Developmental interventions were used for all infants receiving the developmental-care intervention, with varying frequency.     

Intestinal perforations in infants with a very low birth weight: a disease of increasing survival?

Seventeen infants with a very low birth weight (VLBW) and spontaneous, non-necrotizing enterocolitis (NEC), intestinal perforations are presented; 14 of them were seen in the past 3 years. A comparison with 16 surgically treated NEC infants (< 1,000 g) is provided. At our institution, the yearly survival of VLBW infants increased from 54% to 90% over the past 6 years. All 17 non-NEC patients were operated on, and 15 (88.2%) survived. Ileal perforations were observed frequently. Initial enterostomies were followed by reanastomosis at an average age of 3 months. A 22.6-month follow-up was attained for all survivors. Non-NEC intestinal perforations in tiny neonates are increasing and constitute a challenging but treatable group. The improving survival rate of VLBW infants will probably be accompanied by a variety of complications.     

Outcome of very low birth weight infants in industrialized countries: 1947-1987

Neonatal intensive care has led to a progressive improvement in the survival of very low birth weight (VLBW, < 1,500 g) infants. However, it has not been established whether there has been a simultaneous increase or decrease in the prevalence of handicapping conditions in this group of children. To explore this question, a meta-analysis was performed using outcome data of 32 developmental studies of VLBW infants born in industrialized countries between 1947 and 1987. The authors' results show that the proportion of VLBW infants who survived and had an intact outcome progressively increased between 1947 and 1987--from 147 per 1,000 live births in the period 1947-1965 to 498 per 1,000 in the period 1980-1987 (p < 0.01). The prevalence of major handicapping conditions for the subset of VLBW infants who weighed < 1,000 g at birth increased, resulting from the increasing survival rates. However, the prevalence of major handicapping conditions among all children with VLBW decreased from 147 per 1,000 live births in 1947-1965 to 45 per 1,000 in 1980-1987 (p = 0.02). The authors' meta-analysis suggests that improved survival of VLBW infants has not been accompanied by an increase, but more likely a decrease, in the prevalence of handicapping conditions in this birth weight group.     

School performance at nine years of age in very premature and very low birth weight infants: perinatal risk factors and predictors at five years of age. Collaborative Project on Preterm and Small for Gestational Age (POPS) Infants in The Netherlands

Continuous measurement of blood flow velocity during interventional procedures has the potential to provide an early warning of coronary flow instability, which can lead to abrupt closure or other adverse events before angiography. The magnitude and fluctuations of the average velocity over time (trend) was studied by using a 0.018-inch Doppler-tipped angioplasty guide wire in 32 patients after coronary angiography (n = 20), atherectomy (n = 2), urgent stent (n = 6), urgent vein graft thrombolysis (n = 4), or acute myocardial infarction (n = 2). The patients (mean age 60 +/- 11 years) had postprocedural in-laboratory flow monitoring for a mean of 19 +/- 11 (range 8 to 36) minutes. The coronary artery monitored was the left anterior descending in 13, circumflex in 6, right coronary artery in 9, and saphenous vein graft in 4. Seven patients had flow-related events during continuous flow velocity monitoring before serial angiographic study. These events included coronary vasospasm (abrupt flow acceleration), vasovagal flow cessation, cyclical flow variations resulting from accumulation of intraluminal thrombus, and rapid decline of flow velocity. The last two patterns were associated with abrupt vessel closure during angioplasty. Continuous flow velocity monitoring is easily incorporated into routine interventional procedures and provides an early indication of unstable flow and the potential for abrupt vessel closure and other adverse events.     

The structure of the morbidity in very low birth weight premature infants]

A relationship between the qualitative and quantitative characteristics of representatives of the normal microflora in biocenosis of the colonic lumen (CL) was studied in 18 patients with subacute bacterial endocarditis, 18 patients with rheumatic heart disease, 13 with chronic renal failure and 50 healthy individuals without clinical signs of dysbacteriosis. The number of intermicrobial relationships was found to be rather small both in health and in disease. However, a disease shows a considerably greater number of different relations, synergic ones in particular. Analysis indicated that in the conditions under study 72 to 93% of relations that were realized in the healthy human CL biotope disappeared and the established intermicrobial relationships were found 86-97% quite new. Summing up, the authors have concluded that, first, the CL microflora exists under the conditions of excess nutrient substrate and is not a factor of self-regulation, second, changes in the body's metabolic systems are primary in the diseases examined, which the normal lumenal microflora is responsive to.     

Association of fungal colonization and invasive disease in very low birth weight infants

BACKGROUND: Fungi are common pathogens of nosocomial infections in the very low birth weight (VLBW) infants. The purpose of this study was to investigate the fungal colonization rate in VLBW infants and the association between fungal colonization and systemic fungal diseases. MATERIALS: Between January 1, 1996, and December 31, 1996, 116 infants with birth weight < 1500 g admitted to the neonatal intensive care unit of Chang Gung Children's Hospital in the first day of life were included in this prospective study. METHODS: Cultures from oropharynx, rectum, skin (groin and axilla), bag urine and endotracheal aspirates were obtained in the first 24 h after birth and weekly thereafter throughout their neonatal intensive care unit stay. Medical records were reviewed weekly. RESULTS: Fungal colonization was detected in 25 infants, among whom 17 infants developed colonization by 2 weeks of life. Candida albicans (61%) and Candida parapsilosis (29%) were the 2 most common organisms. The rectum (76%) was the most frequent site of colonization. Factors significantly associated with colonization were prolonged administration of antibiotic therapy, parenteral nutrition and intralipid emulsion. Three of 116 infants developed fungemia. The association between colonization and subsequent fungemia was demonstrated in 1 infant, representing 4% of colonized infants. CONCLUSION: Fungal colonization was detected in one-fifth of VLBW infants and represents a risk factor for fungemia. Because disease occurred in the absence of apparent colonization, factors other than colonization may contribute to invasive candidiasis.     

Tracheostomy: acute and long-term mortality and morbidity in very low birth weight premature infants

Thirty-six very low birth weight premature infants (VLBW-PT) born at 24 to 32 weeks gestation and with birth weights 635 to 1,360 g who had tracheostomies performed for acquired subglottic stenosis or for prolonged mechanical ventilation were followed in relation to acute and long-term mortality and morbidity. Mortality due to the tracheostomy occurred in 4 patients (11%); mortality from all other causes was 25%. Death after hospital discharge was associated with the nonuse of prescribed cardiorespiratory monitors. Complications < 1 week postsurgery occurred in 31% of infants and complications > or = 1 week postsurgery occurred in 64% of infants. Fifty percent of infants required tracheostomy for > 2 years and/or extensive reconstructive surgery of the airway. Parents should be counselled that VLBW-PT infants with a tracheostomy may require extended medical and home care. An effective home care program requires parental training in tracheostomy care, the use of ancillary equipment, and infant cardiopulmonary resuscitation.     

Risk status for dropping out of developmental followup for very low birth weight infants

Not keeping scheduled visits for medical care is a major health care issue. Little research has addressed how the interaction of demographic and biomedical parameters with psychosocial processes has an impact on appointment keeping. Typical factors are stress of daily living, methods of coping, social support, and instrumental support (that is, tangible assistance). In this study, the authors examine the role of these parameters and processes in the risk status for dropping out of a developmental followup program for very low birth weight infants. The findings suggest that the stress of daily living is a significant predictor for the mother's return when the infant is 6 months of age (corrected for prematurity). The predictors for return at 24 months corrected age include marital status, race, gestational age of the infant, maternal intelligence, and efficacy expectations. Providing transportation was found to be a successful intervention strategy for a subgroup at very high risk for dropping out due to a constellation of biomedical, demographic, and psychosocial factors.     

Neonatal pediatrics in Denmark. Therapeutic routines in care of very low birth weight infants and very premature infants, 1990

A questionnaire on neonatal carried intensive care in Denmark was carried out in October 1990. The eighteen paediatric departments in the country with neonatal intensive care units all answered the questionnaire. The routines concerning transferral to a higher level of specialization, and the treatment procedures for children with a birthweight below 1500 grams and/or a gestational age under 32 weeks are described. Major regional variations were found in the degree of centralization of treatment, especially between the eastern and western part of Denmark. In an international perspective to neonatal intensive care Denmark seems to be modest with respect to initiation of treatment and the use of technology.     

Surgical ligation of patent ductus arteriosus in very low birth weight infants: is it safe?

We evaluated the outcome of a combined medical and surgical treatment of patent ductus arteriosus (PDA) in newborns weighing less than 1500 g. Charts were retrospectively reviewed for 76 newborns with a PDA between 1993 and 1997. Thirteen infants had pre-existing conditions prohibiting the use of indomethacin; eight were managed surgically, five medically. The remaining 63 infants received indomethacin therapy. Thirty-two medical failures occurred, requiring surgical ligation of the PDA. Those requiring surgery had a lower average birth weight (847 versus 997 g) and gestational age (26 versus 28 weeks; P < 0.05). Indomethacin treatment was successful in 27 infants. There were only three operative complications: a small pneumothorax, wound bleeding, and a small aortic tear. All recovered uneventfully and no deaths were attributable to the surgical procedure itself. There was no difference in the incidence of respiratory distress syndrome, duration of intubation, sepsis, neonatal enterocolitis, renal dysfunction, bleeding disorders, or intraventricular hemorrhage among both groups. Surgical ligation of a PDA is associated with a high success rate, a low incidence of complications, and no additional morbidity than indomethacin alone. We propose that surgical ligation should be regarded as a first line therapy for very small premature infants who are at higher risk of medical failure.     

Pituitary-adrenal suppression in preterm, very low birth weight infants after inhaled fluticasone propionate treatment

Systemic corticosteroids prescribed for treatment of pulmonary diseases in preterm, very low birth weight infants caused severe suppression of the hypothalamic-pituitary-adrenal axis and produced serious physiological and metabolic disturbances. However, the effect of inhaled corticosteroids on their pituitary-adrenal functions is not known. We prospectively evaluate the pituitary-adrenal function using the human CRH stimulation test in a cohort of very low birth weight infants at risk for hypothalamic-pituitary-adrenal axis suppression in a double blind, randomized pilot study designed for assessing the efficacy and adverse effects of inhaled fluticasone propionate in newborn preterm infants who required mechanical ventilation for treatment of respiratory distress syndrome. Twenty-five preterm (< 32 gestational weeks), very low birth weight (< 1500 g) infants were randomized to receive inhaled fluticasone propionate (n = 13) or a placebo inhaler (n = 12). The medication was given every 12 h (fluticasone propionate, 1,000 micrograms/day) for 14 days. All surviving infants had their pituitary-adrenal functions assessed by human CRH test on the following morning immediately after completion of the 2-week course. All basal (0 min) and post-stimulation (15, 30, and 60 min) plasma ACTH and serum cortisol concentrations were significantly suppressed in the inhaled fluticasone group compared to their corresponding levels in the placebo group [basal plasma ACTH concentrations (F = 6.0; P = 0.02), poststimulation plasma ACTH concentrations (F > 8.6; P < 0.01), basal serum cortisol concentrations (F = 5.6; P = 0.03), and poststimulation serum cortisol concentrations (F > 15.6; P < 0.001)]. This is the first study in very low birth weight infants that demonstrates unequivocally that cumulative high dose inhaled corticosteroids can induce moderately severe suppression of both the pituitary and adrenal glands. The systemic bioactivity is probably associated with pulmonary vascular absorption, which effectively circumvents the hepatic first pass metabolism. Until the question of safety can be adequately addressed, inhaled fluticasone propionate should be used with cautionin preterm infants.