An early marker for neurological deficits after perinatal brain lesions

BACKGROUND: In normal awake infants, fidgety movements are seen from the age of 6 weeks to 20 weeks. The aim of the study was to test the predictive value of absent or abnormal spontaneous movements in young infants for the later development of neurological deficits. METHODS: In a collaborative study involving five hospitals we collected data on the normal and abnormal quality of fidgety movements of 130 infants and compared it with assessments of neurological development done longitudinally until the age of 2 years. On the basis of ultrasound scans infants were classified as at low-risk or at high-risk of neurological deficits. Infants were videoed for 1 h every week from birth to discharge and then for 15 min every 3 to 4 weeks; quality of general movements was assessed. Repeated neurological assessments were also done until 24 months of corrected age. FINDINGS: 67 (96%) of 70 infants with normal fidgety movements had a normal neurological outcome. Abnormal quality or total absence of fidgety movements was followed by neurological abnormalities in 57 (95%) of the 60 infants (49 had cerebral palsy and eight had developmental retardation or minor neurological signs). Specificity and sensitivity of fidgety movement assessment were higher (96% and 95%, respectively) than of ultrasound imaging of the infants' brain (83% and 80%, respectively). INTERPRETATION: Our technique of assessing spontaneous motor activity can identify and distinguish between those infants who require early intervention for neurological abnormalities and those who do not. Our technique is simple, non-intrusive, reliable, quick, and can be done on very young infants.     

Does early supplementation affect long-term breastfeeding?

The purpose of this secondary data analysis from two different samples was to examine the effect of early supplementation with manufactured milks on breastfeeding status at 20 weeks postpartum in mothers of healthy term infants. In two convenience samples of 120 and 223, respectively, breastfeeding mothers were followed up for 20 weeks postpartum or until weaning occurred. The breastfeeding rate at 20 weeks postpartum was significantly greater for mothers who reported feeding exclusively mother's milk the second week after delivery compared with mothers who breastfed and simultaneously supplemented with manufactured infant milks. Of the mothers in samples one and two who exclusively fed human milk during week 2 postpartum, 63.0% and 59.7%, respectively, were still breastfeeding at week 20, compared with 28.1% and 24.2%, respectively, who supplemented with artificial milks. There was no significant difference between these two groups of mothers and their intended duration of breastfeeding. Early introduction of supplemental bottles of artificial milks is associated with a decrease in the amount of human milk the infant receives as well as with early weaning.     

Scoring criteria for preimplantation genetic diagnosis of numerical abnormalities for chromosomes X, Y, 13, 16, 18 and 21

Breastfeeding has long been believed to protect against infection in infants, but protection against respiratory illnesses has not been consistently demonstrated in studies in developed countries. Between 1988 and 1992, the authors assessed the effect of breastfeeding on incidence and duration of respiratory illnesses during the first 6 months of life in a prospective study that actively tracked breastfeeding and respiratory illnesses. A cohort of 1,202 healthy infants, born in Albuquerque, New Mexico, between January 1, 1988 and June 30, 1990, from homes without smokers was enrolled. The daily occurrences of respiratory symptoms and breastfeeding status were reported by the mothers every 2 weeks. Illnesses were classified as lower respiratory illness (LRI) if wheezing or wet cough was reported; the remaining illnesses were classified as upper respiratory. The annualized incidence rates for LRI were 2.8, 2.6, and 2.1 during follow-up time with no, partial, or full breastfeeding, respectively, but the incidence rates for upper respiratory illness and lower respiratory illness combined were similar in the three categories. After adjustment for potential confounding factors, full breastfeeding was associated with a reduction in lower respiratory illness risk (odds ratio=0.81, 95% confidence interval 0.68-0.96). Median duration of all respiratory illnesses was 5 days for the fully breastfed infants during the first 6 months of life compared with a median of 6 days for not breastfed and partially breastfed infants. Multivariate analysis confirmed that breastfeeding significantly reduced the duration of respiratory illness. This pattern of reduced incidence of LRI and shorter duration of all respiratory illnesses suggests that breastfeeding reduces the severity of infant respiratory illnesses during the first 6 months of life.     

Infant feeding practices in St. Vincent and factors which affect them

A survey was conducted in the summer of 1975 in 2 towns in St. Vincent--Layou and Georgetown--in the effort to obtain information regarding infant feeding practices and some of the factors which may influence them. Mothers of children from 1-2 years of age were interviewed in their homes. Complete data sets were obtained on 192 of the 216 eligible children in the 2 towns. For most children the period of exclusive breastfeeding (no other milk product given) was very short. About 1/2 of the children had received milk by 2 weeks of age, and 75% by 1 month. This was followed by a much longer period of "mixed" feeding--both breast and bottle--until breastfeeding was stopped at a median age of 6.8 months. Many types of milk were used for infant feeding. For 73% of the infants, infant formula was the 1st type of milk given. This was commonly replaced by a "heavier" full cream powdered milk at a few months of age. Prelacteal feeds were very common, predominantly glucose water. "Tonics," often consisting of vitamin preparations, were another common supplement during the early months of life. Among solid foods, arrowroot, "custard," and commercial infant cereals were the first to be introduced. Relatively inexpensive locally bagged staple foods and milk powders were available in both towns, but most mothers relied heavily on packaged brand name products for infant feeding even though the cost was 2-10 times higher. It was not possible to pinpoint the exact causes for the high levels of bottle feeding, nor for the possible recent decline in breastfeeding, but several important factors were identified. Part of the problem appeared to be due to poor health and nutritional status of the mothers. In addition, in several cases the mothers reported that they had wanted to continue breastfeeding but had received no support from health professionals, and in a few instances had been ordered to stop for seemingly trivial medical reasons.     

Comparison of the cytotoxic activity of melphalan with L-prolyl-m-L-sarcolysyl-L-p-fluorophenylalanine in human tumour cell lines and primary cultures of tumour cells from patients

By means of sequential videotape recordings, the relevance of the quality of general movements for neurological outcome was determined in a group of 21 appropriate-for-gestational-age preterm infants with transient periventricular echodensities of variable localization and duration and in 6 infants without echodensities. Echodensities, especially in the parieto-occipital area, affected the quality of general movements. Echodensities persisting beyond 14d were associated with abnormal general movements; infants with echodensities up to 14 d had either normal or abnormal general movements. The developmental course of movement quality was correlated to neurological outcome (p < 0.005): normal outcomes were found in 11/12 infants with normal general movements throughout and in 9/11 infants with transient abnormal general movements; all 4 infants with persistent abnormal general movements had impaired outcomes. In infants with transient echodensities, longitudinal assessment of the quality of general movements helps to determine if there is brain dysfunction, either transient or persistent, and identifies infants at risk for impaired neurological outcomes.     

Complications of long-term jejunostomy in children

The authors reviewed 64 jejunostomies performed in 57 patients. Data were collected regarding complications and performance of the catheters. Patient diagnoses were grouped as follows: cystic fibrosis (25), neurological impairment (14), and miscellaneous other (25). Indications were malnutrition (43), inability to feed (17), and gastroesophageal reflux (4). Complications were compared between these groups. The age range was 7 days to 23 years. There were 251 tube changes over 142 years of cumulative site patency, for an average of 1.8 tube changes per year and an average life of 2.2 +/- 2.4 years per site. The longest duration was 11.7 years. Four tube changes resulted in intraperitoneal insertion (6.2% of changes). The overall complication rate was 37.5%. The major and minor complication rates were 21.9% each. Some patients had more than one complication. Stratification of complications by diagnosis showed that the highest incidence was among the neurologically impaired children (64%), followed by those with cystic fibrosis (32%) and then others (28%). Sixty-four percent of major and 54% of minor complications occurred within the first 6 months. The mortality rate was 4.7%. Infections requiring intravenous antibiotics occurred in 9.4% of the sites, at an average site age of 8.7 +/- 7.7 months. Tube dislodgment requiring surgical replacement occurred in 9.4% of the patients. Our mortality and complication rates compare favorably to those of previously reported series. Surgical jejunostomy is a reliable long-term solution to feeding but is associated with a significant risk of complications, especially in neurologically impaired children. The risk is greatest in the first 6 months after insertion, then decreases as the site "matures."     

Developmental neurological examinations in preparatory school children (author's transl)

302 primarily healthy preparatory school children aged from 4-6 years were examined neurologically, using a slightly modified Touwen-Prechtl examination scheme. It was possible to make statistically confirmed statements on the individual tests of neurological function for a German kindergarten population. To develop a short (screening) test representative of the entire nervous system would be very difficult indeed. We hope, however, by means of rational data reduction, to be able to find a compromise between the complexity of the nervous system and the necessities of practice.     

Breast-feeding in Egypt

Planning, implementation and evaluation of programmes to promote appropriate infant feeding practices require detailed, current information about these practices in the target populations. To estimate the prevalences and identify the correlates of overall breast-feeding and of exclusive breast-feeding in different age periods during infancy, a cohort of 152 apparently healthy neonates and their mothers were followed during October 1987 through April 1989 in rural Bilbeis, Sharqiya Governorate, Egypt. Feeding data were collected through twice weekly home visits thus reducing the potential for bias in our findings due to respondent recall errors. The prevalence of overall breastfeeding in the infants declined from 100% in age period 0-11 weeks to 89% in age period 36-47 weeks. Mothers with previous living children were associated with significantly higher (odds ratio [OR]: 6.53, 95% confidence interval [CI]: 1.33-32.09) and ownership of refrigerators was associated with significantly lower (OR: 0.18, 95% CI: 0.05-0.67) overall breast-feeding prevalences in age periods 24-35 and 36-47 weeks, respectively. The prevalence of exclusive breast-feeding in breast-fed infants dropped from 20% in age period 0-11 weeks to 0% in age period 36-47 weeks. After multivariate adjustment, prelacteal feeding was significantly negatively (OR: 0.12, 95% CI: 0.04-0.37) associated with exclusive breast-feeding in age period 0-11 weeks. Nearly 90% of Bilbeis infants were breast-fed at age 47 weeks, but the initiation of supplementation at 0-11 weeks in 80% of breast-fed infants is contrary to current recommendations.(ABSTRACT TRUNCATED AT 250 WORDS)     

An optimality score for the neurologic examination of the term newborn

We describe the application of a revised version of the Dubowitz neurologic examination of the newborn in 224 low-risk, term newborn infants. The method has been updated by eliminating less useful items and including new items evaluating general movements and patterns of distribution of tone. An optimality score is included to make the evaluation more quantitative and for comparison with sequential examinations with neurophysiologic and imaging findings. The score is based on the distribution of the scores for each item in the population of low-risk term infants. We defined not only the most common pattern for each item but also the variability of the findings by using 10th and 5th centiles. Because most of the items assessing tone and the Moro reflex varied with gestational age between 37 and 42 weeks, the changes were incorporated in the scoring system. The total optimality score was the sum of the optimality scores of individual items. Although the association of 4 or more deviant scores was found in less than 10% of our infants, deviant results on 1 or 2 single items could be observed in a third of this normal population, suggesting that isolated deviant signs have little diagnostic value. In contrast, an abnormal distribution of tone patterns, which we have commonly observed in infants with brain lesions, was not found in this cohort.     

Identification of Nramp2 as an iron transport protein: another piece of the intestinal iron absorption puzzle

The attitudes of young men and women to breastfeeding were examined including perceived incentives and barriers to the practice in cross sectional survey and focus group discussion. The study involoved 177 (100%) fifth and final year students of both sexes and a subsample of 48 students in 6 focus groups in three post primary schools in an Irish midland town. Overall 28% reported that they themselves were breastfed. The most frequent sources of information were the media rather than home or school. A majority of girls (86%) and boys (77%) agreed that breastfeeding was the best method of feeding, but less intended the practice for their children (54%), girls being significantly less likely than boys. There were no patterns in relation to social class and lifestyle. Reasons for breastfeeding in the focus groups included its naturalness, facility of feeding and adequate nourishment. Reasons against related to embarrassment in public, but mainly related to perceived problems with the practicalities of feeding. Health promotion strategies need to reach young people before they initiate pregnancies. Skills based health education courses would be helpful and girls should be aware of the positive attitudes of boys generally.     

Radicular compression by brucellar epidural abscess

Fifteen children with protein-energy malnutrition and eight healthy children between the ages of 6 months and 60 months were studied for blood glucose and serum insulin levels in the fasting state and 120 minutes following oral glucose load. The measurements were repeated after normalization of the body weight following 6 weeks of nutritional rehabilitation. The fasting blood glucose increased significantly in the post-treatment period and became comparable to the control value. The abnormal blood glucose response to oral glucose load also normalized. The serum insulin level rose significantly (p < 0.001) in the post-treatment period but failed to normalize. The response to oral glucose load was similar. The observed lower insulin response, despite normoglycemia, after 6 weeks of nutritional rehabilitation indicates persistence of hormonal imbalance which may need a longer duration of rehabilitation for full recovery.     

Breastfeeding, maternal smoking and lower respiratory tract infections

The objective of the study was to assess the relationship between breastfeeding and lower respiratory tract infections (LRTIs) during the first year of life, with special reference to maternal smoking. A cohort of 3,754 children born in 1992-1993 in the City of Oslo, Norway was recruited and data were collected at birth, 6 and 12 months of age. Complete information was obtained from 3,238 children (follow-up rate 86%). The main outcome was an episode of a LRTI, such as pneumonia, bronchitis or bronchiolitis, based on a self-administered questionnaire addressed to parents when the child was 6 and 12 months old. The outcome was specified as physician-diagnosed. In logistic regression analysis adjusting for confounding, maternal smoking increased the risk of LRTIs in children breastfed for 0-6 months (odds ratio (AOR) 1.7; 95% confidence interval (95% CI) 1.2-2.4), but not essentially when the child was breastfed for more than 6 months (AOR 1.1; 95% CI 0.7-1.6). Short-term breastfeeding (0-6 months) and no maternal smoking was related to an adjusted AOR of LRTIs of 1.3 (95% CI 1.0-1.7), and short-term breastfeeding combined with maternal smoking was related to an adjusted AOR of 2.2 (95% CI 1.6-3.1), as compared with long-term breastfeeding and no maternal smoking. The present study indicates a protective effect of long-term breastfeeding on the risk of lower respiratory tract infection during the first year of life. The results suggest that the protective effect is strongest in children exposed to environmental tobacco smoke.     

Factors influencing the duration of breast-feeding

A group of 239 Scottish mothers breastfeeding on leaving hospital were followed up 6 months later by a postal questionnaire. 216 (90%) responded. Of these, 41% had discontinued breastfeeding before the end of the 12th week, the greatest decline occurring within the 1st 6 weeks. Duration of breastfeeding was significantly influenced by social class and, for parous mothers, previous breastfeeding success. 72% of the mother who stopped breastfeeding within the 1st 12 weeks gave inadequacy of the milk supply or an unsettled baby as contributory reasons. Maternal fatigue and painful nipples were the other 2 most frequent contributory problems. Only 6% of all mothers admitted to not enjoying breastfeeding. The person most commonly consulted about breastfeeding problems was the health visitor. Regardless of how long they had breastfed, 43% of the mothers would have liked more help.     

The utility of chest radiography in the follow-up of pneumonia

AIM: We conducted this study to determine whether chest radiography was clinically useful in the follow-up of uncomplicated pneumonia affecting children aged between 6 weeks and 15 years. METHOD: We examined the case records of all 78 paediatric admissions for pneumonia to our hospital over one year. Thirteen children were excluded on account of age or other complicating factors. RESULTS: Of the 65 study cases, the mean age was 3.5 years (range 0.4-13 years). On admission 51 (79%) had cough, 53 (82%) fever, 53 (82%) tachypnoea and 50 (77%) had abnormal chest signs. Elevation of C reactive protein was recorded in 43 (66%) cases and leukocytosis in 42 (65%). All children received initial chest radiographs which showed unilobular/lobar changes in 34 (53%), bilobar changes in 19 (29%) and diffuse abnormalities in 7 (11%). Forty-one patients were followed up both clinically and radiologically, usually (31 cases) between four and six weeks after discharge. Thirty-seven children had no abnormal symptoms or signs and had normal chest radiographs. The remaining four had symptoms and signs, their radiographs showed either slight resolution or no change from the admission films. CONCLUSION: In cases of uncomplicated pneumonia, follow-up chest radiography should be deferred until at least four weeks after discharge and is not indicated if symptoms and signs are absent.     

Interleukin-6 and interleukin-8 in the urine of children with acute pyelonephritis

Interleukin-6 (IL-6) and interleukin-8 (IL-8) are important mediators of the inflammatory response in serious bacterial infections. We studied the levels of these two cytokines (standardised for urinary creatinine) in the urine of infants and children during and 6 weeks after acute pyelonephritis and in non-renal febrile controls and healthy children without apparent infection. IL-6 was detected in the urine of 52% of children with pyelonephritis compared with 15% of other children (P < 0.001). The median urinary IL-6 level in acute pyelonephritis was 4 pg/mumol compared with undetectable levels in the control group (P < 0.001). IL-8 was detected in 98% of children with pyelonephritis and 42% of other children (P < 0.001). The median concentration of IL-8 was 188 pg/mumol in pyelonephritis; it was undetectable in controls (P < 0.001). IL-8 levels were higher in children less than 1 year of age (P < 0.001).     

Risk factors for preeclampsia, abruptio placentae, and adverse neonatal outcomes among women with chronic hypertension. National Institute of Child Health and Human Development Network of Maternal-Fetal Medicine Units

The study comprised 80 children aged 6 to 9 years with a history of febrile convulsions. A neurological examination, an interview to assess psychiatric anomalies, and a series of neuropsychological tests were performed on patients with previous febrile convulsions and on matched healthy controls. Children with non-febrile seizures or CNS infections were excluded. Recurrence of febrile seizures in the study group was 41% (N=33), 18 children (22%) had prolonged febrile convulsions, six (7.5%) patients and two controls showed discrete neurological abnormalities. Behavioral anomalies were exhibited by 22% of the patients and 6% of the healthy children. The neuropsychological test results did not demonstrate significant differences between the children with febrile convulsions and the healthy controls. However, in children with prolonged febrile convulsions, non-verbal intelligence was found to be significantly lower as compared with children with simple febrile seizures and with controls. None of the other parameters tested yielded any differences between patients and controls. Children with multiple recurrences of febrile convulsions performed poorer in all tests when compared with children with only one febrile seizure or with controls. Other factors such as a positive family history of epilepsy, age at onset of febrile convulsions, or duration of the seizure were not found to be of prognostic significance.     

UNICEF/WHO baby-friendly hospital initiative: does the use of bottles and pacifiers in the neonatal nursery prevent successful breastfeeding? Neonatal Study Group

To promote breastfeeding, UNICEF/WHO have launched the "baby-friendly hospital initiative" focusing on hospital care routines during delivery and the first days of life. In industrialised countries, two aspects of the initiative have raised controversy: how do restriction of supplemental feedings and ban of bottles and pacifiers affect long-term breastfeeding performance? From ten centres 602 healthy newborns were randomly assigned either to a UNICEF group with restrictive fluid supplements and avoidance of bottles and pacifiers during the first 5 days of life, or to a standard group with conventional feeding practice. Breastfeeding was encouraged in both groups. The main study endpoints were the prevalences of breast-feeding on day 5, and after 2, 4 and 6 months. Of the newborns 46% violated the UNICEF protocol, mostly because of maternal requests to give a pacifier or supplements by bottle. In the standard group, the drop-out rate was 9.7%. No significant differences in breastfeeding frequency and duration could be found: (UNICEF vs standard) day 5: 100% vs 99%; 2 months: 88% vs 88%; 4 months: 75% vs 71%; 6 months: 57% vs 55%. Inclusion of drop-outs due to pacifier use did not alter the results. Conclusion: In our study population fluid supplements offered by bottle with or without the use of pacifiers during the first 5 days of life were not associated with a lower frequency or shorter duration of breastfeeding during the first 6 months of life.     

Warfarin monitoring independent of the international normalized ratio (INR): a pilot study

Post-operative feeding techniques for infants following primary repair of cleft lip vary considerably. Recommendations range from immediate return to nipple feeding post-operatively to abstinence from nipple feeding for up to 6 weeks. Different surgeons prescribe different post-operative feeding protocols among and within centers. The purposes of this retrospective study (n = 42) were to: (1) identify the specific nonnipple feeding guidelines given to caregivers prior to surgery and the duration for those practices to be used in the post-operative period, (2) describe caregiver compliance, and (3) identify post-operative complications (e.g. dehiscence) related to type and duration of feeding strategies. Feeding guidelines included: nonnipple feeding for 6 weeks (n = 28, 67%), 3 weeks (n = 6, 14%), 2 weeks (n = 6, 14%), and unrestricted return to nipple (n = 2, 5%). Nearly all caregivers (n = 37, 88%) complied with recommendations. The others (n = 5, 12%) returned their infants to nipple feeding sooner than recommended (three in the nonnipple group for 6 weeks, and one each in the other two groups). No medical/surgical complications were related to feeding strategies. Conclusion: caregivers typically comply with post-operative feeding recommendations. However, the variability in those recommendations should be reduced with feeding made as easy as possible and not a jeopardy to wound healing.     

Abnormal fetal aortic velocity waveform and minor neurological dysfunction at 7 years of age

Measurements of fetal aortic blood flow velocity and fetal growth were performed in 178 pregnancies. In 87 cases, the estimated fetal weight was > or = 2 SD below the gestational age-related mean of the population. Three fetuses died in utero. In 149 children (85%), a neurological examination was performed at 7 years of age with special emphasis on minor neurological dysfunction. The frequency of the more severe form of minor neurological dysfunction, MND-2, was higher in the group with blood flow class (BFC) III (absent or reversed end-diastolic flow velocity (8/21) than in the group with BFC 0 (normal velocity waveform) (14/105). Logistic regression analysis revealed that abnormal blood flow class, both independently and in combination with other factors, was the most significant predictor of MND-2. The association found between abnormal fetal aortic velocity waveforms and adverse outcome in terms of minor neurological dysfunction suggests that hemodynamic evaluation of the fetus has a predictive value regarding postnatal neurological development.     

Epileptic aphasia: a consequence of regional hypometabolic encephalopathy?

A series of 25 children, 13 females and 12 males, who had an acquired communication disorder together with epilepsy, but did not fulfil the strict criteria of the Landau-Kleffner syndrome, was studied. All children had a clinical neurological evaluation, speech and language assessment, an awake and sleep EEG, cranial MRI, SPET scan, and audiometry. Clinical seizures were most often polymorphic in type (17 of 25). Atypical absences were the commonest individual seizure type occurring in 15 cases. All patients had an unequivocal epileptiform EEG. Normal sleep phenomena were only observed in 10 cases, enhancement of epileptiform activity in sleep was seen in 16. Cranial MRI was abnormal in six and normal in 19 cases. The SPET scans were abnormal in 22 of 25 children. The language deficits were classified neurologically as receptive aphasia, 24 of 25; expressive aphasia, 20 of 25; nominal aphasia, eight of 25; articulatory dyspraxia, 10 of 25; and auditory agnosia, nine of 25. It is hypothesized that the loss of communication skills is due to an encephalopathy secondary to the persistent epileptic discharge and manifests as a hypometabolic area on the SPET scan.