Withholding and withdrawing life sustaining treatment in neonatal intensive care: issues for the 1990s.
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Decision Making↗
Biomedical subjects
S Saigal
Publications and source records attributed to S Saigal.
A randomized, controlled trial of platelet transfusions in thrombocytopenic premature infants.
A multicenter prospective, randomized controlled trial was conducted to determine whether early use of platelet concentrates would reduce the incidence or extension of intracranial hemorrhage or both in sick preterm infants with thrombocytopenia. The effects on bleeding as reflected by the amount of blood product support administered and a shortened bleeding time were assessed as secondary outcomes. Premature infants with a platelet count < 150 x 10(9)/L within the first 72 hours of life were randomly assigned to receive either conventional therapy or conventional therapy plus platelet concentrates (10 ml/kg). The platelet count was maintained < 150 x 10(9)/L until day 7 of life by one to three platelet transfusions. In 22 (28%) of the 78 treated infants and 19 (26%) of the 74 control infants, either a new intracranial hemorrhage developed or an already-present one became more extensive (p = 0.73). Similar numbers of infants had each grade of intracranial hemorrhage on both initial and follow-up ultrasonography. Similar numbers of infants received fresh frozen plasma and packed red blood cells, but treated infants received less of both. The bleeding time was prolonged in the treated group before the infusion of platelet concentrates but subsequently shortened (mean difference, 79.0; 95% confidence interval, 73.1 to 84.9). Subanalysis of the control group showed that infants with platelet counts < 60 x 10(9)/L (n = 21) on at least one occasion received more fresh frozen plasma and packed red blood cells than did those with platelet counts > 60 x 10(9)/L.(ABSTRACT TRUNCATED AT 250 WORDS)
Blood Component Transfusion↗
'Functional status of extremely preterm infants at kindergarten entry'.
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Child, Preschool↗
Non-right handedness among ELBW and term children at eight years in relation to cognitive function and school performance.
The relationship between handedness, neurological and cognitive deficits, and school difficulties was investigated in 114 extremely low-birthweight (ELBW) children and 145 term controls at eight years. The prevalence of non-right handedness (left and mixed) was 31 per cent for ELBW children and 19 per cent for controls. ELBW children with neurological impairments were significantly more likely to be non-right handed. No significant differences were noted between right-handed and non-right handed ELBW children and controls on tests of cognitive function, school performance and prevalence of learning difficulties. These findings suggest an association between neurological impairment and non-right handedness, but do not support the hypothesis of early brain insult resulting in subtle cognitive deficits and suboptimal school performance among non-right handed ELBW children.
Achievement↗
Can learning disabilities in children who were extremely low birth weight be identified at school entry?
This prospective study was designed to test the hypothesis that a significant proportion of extremely low birth weight (ELBW) children identified as "at risk" for school problems at age 5 years by the Florida Kindergarten Screening Battery (FKSB) will present with specific learning disability (LD) when retested at age 8 years. A regional cohort of 81 of 84 ELBW survivors born between 1980 and 1982 were reassessed at age 8 years by Wechsler Intelligence Scale for Children-Revised (WISC-R), Wide Range Achievement Test-Revised (WRAT-R), and tests of motor function. The association of FKSB risk status and WRAT-R reading subtest for predicting general reading disability in the overall sample at age 8 years resulted in a sensitivity of 0.68, specificity of 0.48, and a likelihood ratio of 1.3. Of the 43 "normal" children at age 5 years with no neurosensory impairments and IQ > or = 84 (McCarthy GCI), 49% were considered to be at "mild" to "high" risk for future LD. The prevalence of specific LD (reading disorder) at age 8 years in children with normal IQ (WISC-R > or = 85) was 28%. The positive predictive value of the 5-year FKSB for identifying children with specific LD at age 8 years was 0.20 (sensitivity 0.33, specificity 0.48). We conclude the FKSB is not an efficient tool for predicting either general or specific LD in ELBW children.
Achievement↗
Cognitive abilities and school performance of extremely low birth weight children and matched term control children at age 8 years: a regional study.
The intellectual, psychoeducational, and functional status of a regional cohort of extremely low birth weight (ELBW) survivors who weighed 501 to 1000 gm at birth (n = 143) and who were born between 1977 and 1981 was compared with that of control children born at term (n = 145) who were matched for gender, age, and social class. One hundred twenty-nine ELBW survivors (90%) were available; their mean birth weight was 839 +/- 124 gm and mean gestational age 27 +/- 2.1 weeks, and 48 of them weighed less than or equal to 800 gm at birth. Both ELBW and control groups were tested at a mean unadjusted age of 8 years; 113 of 129 ELBW children completed the full test battery, eight blind children had other tests, and eight were not testable. The mean Full Scale IQ (Wechsler Intelligence Scale for Children--Revised) was 91 +/- 16 for ELBW children and 104 +/- 12 for control children (p less than 0.0001). Between 8% and 12% of the ELBW group scored in the "abnormal" range (less than or equal to -2 SD) on the Wechsler IQ and subtests, compared with 1% to 2% of the control group. The ELBW group did less well on the reading, spelling, and mathematics tests (Wide Range Achievement Test--Revised less than or equal to -2 SD: ELBW = 20% to 28%; control = 3% to 10%). The motor performance of the ELBW group (Bruininks-Oseretsky Test of Motor Proficiency less than or equal to -2 SD: ELBW = 20%; control = 1%) and their visual-motor integration (Beery Developmental Test of Visual-Motor Integration less than or equal to -2 SD: ELBW = 21%; control = 6%) were also poorer. Exclusion of 19 ELBW children with neurologic impairments or an IQ less than or equal to 70 or both did not result in significant improvement in Wechsler or achievement measures. Approximately 15% of the ELBW cohort performed in the abnormal range on the Vineland Adaptive Behavior Scales, compared with none of the control group. Although approximately two thirds of the ELBW group were performing in the normal range on intellectual measures, comparison with the control group suggests that, as a group, ELBW children were significantly disadvantaged on every measure tested.
Achievement↗
Learning disabilities and school problems in a regional cohort of extremely low birth weight (less than 1000 G) children: a comparison with term controls.
We compared the prevalence of learning disabilities at age 8 years in a subgroup of 68 of 129 (53%) regional cohort of extremely low birth weight (ELBW) children who were considered "normal" neurologically and intellectually (IQ greater than or equal to 85) with that of 114 term group matched controls (C). Both groups were tested with a battery of psychoeducational measures, and parents and teachers completed questionnaires on the school performance of the children. ELBW children were comparable with C on measures of intelligence (ELBW 101 +/- 8, C 104 +/- 11), language, and academic achievement but fared significantly less well in motor performance (p less than .0001). The prevalence of learning disabilities (by predefined criteria) in ELBW children (26%) was not increased compared with C (19%). However, teachers rated significantly more ELBW children as performing below grade level than were C (31% vs 16%, p less than .05), and by parent report, a higher proportion of ELBW children had received special assistance in school compared with C (37% vs 16%, p less than .001). We conclude that although the prevalence of learning disabilities in normal ELBW children was not different from that in controls, ELBW children did less well and utilized more special resources.
Achievement↗
Intellectual and functional status at school entry of children who weighed 1000 grams or less at birth: a regional perspective of births in the 1980s.
The intellectual and functional status of a regional cohort of children who weighed 501 to 1000 gm when born between 1980 and 1982 was evaluated at a mean age of 5 1/2 years by standard psychometric tests. Of 90 long-term survivors (survival rate 49%), 78 children (87%) had the full test battery, 5 children (6%) had other tests (4 were blind), and one child was untestable. Most of the mean scores were within 1 SD of the test norms; the lowest scores were in the McCarthy Motor scale and in the Beery Test of Visual-Motor Integration. Children without neurologic impairments and those with an IQ greater than or equal to 68 (n = 60) had higher overall scores but still performed poorly on the Motor subscale and the Beery test. Children who weighed less than 800 gm at birth (n = 28) were similar to those who weighed greater than 800 gm (n = 50), except in the Memory and Motor subscales, in which they performed significantly less well. At a functional level, determined by the Vineland Adaptive Behaviour Scales, two thirds of the children were performing in the adequate range and the remainder in the moderately low to low range. Of the 43 children with no neurosensory impairments and an IQ greater than or equal to 84, 49% were identified (by the Florida Kindergarten Screening Battery) to be at mild to high risk for future learning disabilities. The data from this unselected population provide an unbiased estimate of the prevalence of intellectual and functional problems in children who weighed less than or equal to 1000 gm at birth.
Anthropometry↗
Psychiatric disorders at five years among children with birthweights less than 1000g: a regional perspective.
The relationship between extremely low birthweight (ELBW) and psychiatric disorder was investigated in a cohort of children of 500 to 1000g birthweight, born between 1980 and 1982. At five years of age data were collected for 82 of 90 survivors on psychiatric symptoms, parent-reported developmental delay and various aspects of psychosocial disadvantage. Compared with controls, ELBW children did not come from more disadvantaged environments, but were much more likely to experience developmental delay and problems with motor co-ordination. 16 per cent had an attention deficit disorder with hyperactivity (ADDH), compared with 6.9 per cent of controls. Rates of conduct disorder and emotional disorder were not raised, indicating that ELBW is a specific risk factor for ADDH. Controlling for the effect of neurodevelopmental problems rendered the association between ELBW and ADDH non-significant.
Attention Deficit Disorder with Hyperactivity↗
Decreased disability rate among 3-year-old survivors weighing 501 to 1000 grams at birth and born to residents of a geographically defined region from 1981 to 1984 compared with 1977 to 1980.
In this article we report the survival and morbidity rates for all live-born infants weighing 501 to 1000 gram at birth and born to residents of a defined geographic region from 1977 to 1980 (n = 255) compared with 1981 to 1984 (n = 266). During these periods, there were no changes in the proportion of infants delivered at the tertiary care center or community hospitals (171/84 vs 194/72); use of the tertiary care center increased only slightly, from 84% to 91%; and changes in neonatal management were mainly in improvements in diagnostic and monitoring techniques. When infants were grouped according to birth weights in 100 gm increments, survival improved significantly only for infants weighing between 501 and 600 gm at birth (2% vs 20% p less than 0.001). There were no differences in the overall survival rates to hospital discharge (46% vs 48%). The prevalence of neurosensory impairments was 24% in period 1 and 17% in period 2. There was a significant improvement in the proportion of infants considered to have disabilities by a functional classification assigned at 3 years corrected age (50% vs 27%, p less than 0.001), but only for infants weighing more than 800 gm at birth (49% vs 22%, p less than 0.001). Infants delivered at the community hospitals had a higher prevalence of neurosensory impairments compared with infants delivered at the tertiary care center (period 1, 35% vs 21%, not significant; period 2, 37% vs 14%, p less than 0.05). These data are encouraging; further efforts should be directed toward assessing which, if any, components of perinatal care are contributing to the improvement in morbidity rates.
Academic Medical Centers↗
Clinical impact of neonatal thrombocytopenia.
In a 1-year prospective study, the outcome in infants with a platelet count less than 100 X 10(9)/L (n = 97) was compared with the outcome in an age-, weight-, and disease-matched nonthrombocytopenic control group (n = 80). The hemostatic impact of the thrombocytopenia was assessed by modified template bleeding time, hemorrhage score, and determination of the presence and extent of intraventricular hemorrhage (IVH) in thrombocytopenic infants weighing less than 1500 at birth (n = 39) compared with all nonthrombocytopenic infants less than 1500 g (n = 122) admitted during the study period. The development outcome in infants less than 1500 g was compared at 12 months after delivery. Neonatal thrombocytopenia had a major impact on hemostatic integrity: bleeding time was inversely related to platelet count (r = -0.56, P less than 0.001) and became prolonged when the platelet count fell to less than 100 X 10(9)/L. In addition, many infants (40%) had evidence of platelet dysfunction with prolonged bleeding times despite only moderately reduced platelet counts (75 to 150 X 10(9)/L). The hemorrhage score was greater in the thrombocytopenic infants compared with the sick control infants, and increased as the platelet count fell (r = -0.58, P less than 0.001). The incidence of IVH in thrombocytopenic infants less than 1500 g was 78%, compared with 48% in the nonthrombocytopenic infants (P less than 0.01). In addition, the more severe grades of IVH were more frequent in the thrombocytopenic infants. The serious neurologic morbidity for the surviving infants less than 1500 g was 41% in the thrombocytopenic infants and 7% in the nonthrombocytopenic infants. Thus, on the basis of three indices of abnormal bleeding, thrombocytopenic infants are at greater risk for bleeding than equally sick nonthrombocytopenic infants. The thrombocytopenia itself may have contributed to the high mortality and neurologic morbidity.
Bleeding Time↗
Long-term outcome of preterm infants with respiratory disease.
Improved survival of preterm ventilated infants has resulted in an increase in the incidence of bronchopulmonary dysplasia, particularly in very tiny infants. In this article, the authors have reviewed the current literature on the pulmonary function and long-term neurodevelopmental outcome of VLBW infants to determine the true morbidity of respiratory disease in the neonatal period.
Bronchopulmonary Dysplasia↗
Tactile/kinesthetic stimulation effects on preterm neonates.
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Humans↗
Randomized clinical trial of an oscillating air mattress in preterm infants: effect on apnea, growth, and development.
To investigate claims that oscillating mattresses reduce apnea of prematurity and improve growth and neurobehavioural development, we performed a randomized clinical trial using a predetermined sample size. Preterm infants weighing from 750 to 1750 gm at birth were randomly assigned, by 250 gm strata, to either a conventional mattress (n = 63) or to an air mattress (n = 59) oscillating at 14 to 16 regular pulses per minute. Infants remained on the oscillating air mattress for at least 7 days or until 34 weeks postmenstrual age. Apneic episodes occurred and required treatment equally in the two groups; this lack of an effect was seen for both sexes and all weight groups. Both weight and energy intake were similar. Neurobehavioral development as shown by sleep state, habituation testing, and behavioral assessment at term, 3, 6, and 12 months was similar in the two groups. There was no difference in the incidence of neurologic abnormalities. We conclude that an oscillating air mattress has no prophylactic value in reducing apnea and does not enhance growth and development.
Air↗
Outcome in infants 501 to 1000 gm birth weight delivered to residents of the McMaster Health Region.
The mortality and morbidity for all 255 live births of infants with birth weight 501 to 1000 gm and delivered to residents of a geographically defined region between 1977 and 1980 are reported. In all, 117 (46%) infants were discharged alive; there were four postdischarge deaths, and three infants were lost to follow-up. The mean birth weight and gestational age of the survivors was 850 +/- 118 gm and 27.1 +/- 2 weeks, respectively. Neurosensory handicaps were detected in 26 (24%) of 110 survivors followed for a minimum of 2 years corrected age. In addition, 29 (26%) infants had nonneurologic problems and 55 (50%) were considered apparently normal. Within 100 gm birth weight groups, survival improved significantly with increasing birth weight, but the handicap rate among survivors remained relatively constant. These figures are proposed for use in describing the current prognosis at birth for liveborn tiny infants from comparable unselected populations.
Anthropometry↗
Neonatal cytomegalovirus infections: the relative role of neonatal blood transfusion and maternal exposure.
A prospective study of premature infants admitted to an intensive care neonatal unit was undertaken to evaluate the relative role of blood transfusions and maternal exposure in infections caused by cytomegalovirus (CMV), varicella zoster virus (VZV) and herpes simplex virus (HSV). During the first year of life, 13.7%, 4.8% and 4% of the infants became infected with CMV, VZV and HSV, respectively, as determined by virus isolation or seroconversion. Transfusion in the newborn period did not influence the rates of VZV or HSV infections. A higher rate of CMV infections occurred in transfused (18.8%) than in non-transfused (11%) infants but the difference was not statistically significant. A significant correlation was found between maternal antibody titers and the rate of CMV infection in infants whether or not transfusion occurred. An even stronger association was found between breast feeding and CMV infections. The risk of alloimmunization to erythrocyte and leucocyte antigens was also assessed; no evidence of increased alloimmunization to these antigens was associated with transfusion.
Antibodies, Viral↗
Spontaneous preterm labour and delivery at under 34 weeks' gestation.
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Breech Presentation↗
Effect of delivery method on outcomes in the very low-birth weight breech infant: is the improved survival related to cesarean section or other perinatal care maneuvers?
The perinatal mortality rate among very low-birth weight infants has been decreased by 20% during the last 4 years of the 1973 to 1980 period here reported. The concurrent increase in the cesarean section rate from 11.9% to 49.1% during the same time frames has been assumed to be responsible for the improved outcome. The changes were most marked in the extremely low-birth weight group (less than 1,000 gm). The survival rates and cesarean section rates were examined among infants of similar birth weight and gestational age in the vertex presentation, in the same time frames. A similar or greater reduction in mortality rate (from 85% to 45%) was noted in the very low-birth weight vertex infants, whereas the cesarean section rate remained minimally and not significantly increased (14.2% to 22.2%). The interpretation of this finding is by no means clear but must include the hypothesis that the increased cesarean section rate may be incidental and in no way related to the improved outcome. The most statistically significant determinants of outcome remain birth weight and gestational age strata, with no significant difference in outcomes when the extremely low-birth weight group is analyzed separately from the entire very low-birth weight group. As yet unidentified perinatal care practices, other than cesarean section, may be more likely to affect outcome in this high-risk group.
Birth Weight↗