Modern Neonatal Intensive Care Research Articles

Intraventricular Hemorrhage in Premature Infants

Four major varieties of intracranial hemorrhage can be recognized in the neonatal period: (1) subdural hemorrhage, (2) primary subarachnoid hemorrhage, (3) intracerebellar hemorrhage, and (4) periventricular-intraventricular hemorrhage.1 Subdural hemorrhage, often related to obstetrical trauma, now is an uncommon lesion in most medical centers. Primary subarachnoid hemorrhage, although very common, is rarely of major clinical importance, because of its venous origin and self-limited course. Intracerebellar hemorrhage, commonly observed at postmortem examination of the small premature infant but rarely documented during life, is of uncertain clinical significance. Periventricular-intraventricular hemorrhage is the most common and serious variety of neonatal intracranial hemorrhage. The enormous importance of this lesion is linked to the remarkable improvements in recent years in neonatal intensive care and, as a consequence, in survival rates for small premature infants. Because periventricular-intraventricular hemorrhage is characteristic of the premature infant (particularly the infant less than approximately 32 weeks gestation), the lesion has reached nearly epidemic proportions in modern neonatal intensive care facilities. INCIDENCE The remarkably high incidence of periventricular-intraventricular hemorrhage is demonstrated dramatically by studies in which premature infants were subjected to computed tomography (CT) scan routinely within the first week of life (Table 1). Thus, 40% to 45% of all such infants exhibited periventricular-intraventricular hemorrhage.2,3

Evaluation of neonatal periventricular-intraventricular hemorrhage. A major advance.

Periventricular-intraventricular hemorrhage is the most common and serious variety of neonatal intracranial hemorrhage. 1 The other major types of hemorrhage, ie, subdural hemorrhage, primary subarachnoid hemorrhage, and intracerebellar hemorrhage, are either very uncommon or not of major clinical importance. The enormous importance of periventricular-intraventricular hemorrhage is linked to the evolution of neonatal intensive care and, as a consequence, the dramatic improvements in survival rates for small pre-mature infants. Because periventricular-intraventricular hemorrhage is characteristic of such infants, the occurrence of the lesion has reached nearly epidemic proportions in modern neonatal intensive care facilities. The adaptation of the computerized tomographic (CT) scan to the evaluation of the small premature infant in the mid-1970s led to the recognition of the remarkably high incidence of the lesion. Thus, in two large studies in which small premature infants were subjected to CT scan routinely in the first week of life, the incidence of periventricular-intraventricular hemorrhage

Intraventricular Hemorrhage in Premature Infants

Four major varieties of intracranial hemorrhage can be recognized in the neonatal period: (1) subdural hemorrhage, (2) primary subarachnoid hemorrhage, (3) intracerebellar hemorrhage, and (4) periventricular-intraventricular hemorrhage.1 Subdural hemorrhage, often related to obstetrical trauma, now is an uncommon lesion in most medical centers. Primary subarachnoid hemorrhage, although very common, is rarely of major clinical importance, because of its venous origin and self-limited course. Intracerebellar hemorrhage, commonly observed at postmortem examination of the small premature infant but rarely documented during life, is of uncertain clinical significance. Periventricular-intraventricular hemorrhage is the most common and serious variety of neonatal intracranial hemorrhage. The enormous importance of this lesion is linked to the remarkable improvements in recent years in neonatal intensive care and, as a consequence, in survival rates for small premature infants. Because periventricular-intraventricular hemorrhage is characteristic of the premature infant (particularly the infant less than approximately 32 weeks gestation), the lesion has reached nearly epidemic proportions in modern neonatal intensive care facilities. INCIDENCE The remarkably high incidence of periventricular-intraventricular hemorrhage is demonstrated dramatically by studies in which premature infants were subjected to computed tomography (CT) scan routinely within the first week of life (Table 1). Thus, 40% to 45% of all such infants exhibited periventricular-intraventricular hemorrhage.2,3

PITFALLS IN EVALUATION OF THE NEONATAL ICU

The crucial test of the effectiveness of modern neonatal intensive care is outcome for infants weighing 1500 gm or less at birth. Reports indicate decrease in mortality and an apparent decrease in neuropsychiatric disability in the few instances where followup is done. Data from our center also indicate a significant drop in both mortality and morbidity, with better outcome for those born in than for those transferred. But are populations of two decades ago comparable to today's? Do reports include both inborns and transfers then and now? There could be fewer in the under 1500 gm group born today because of better prenatal nutrition and affluence or because of more abortions or greater use of birth control in those young and/or unwed at high risk of having very low birth weight infants. What are the reasons for transfer and when does it take place? Decades ago infants usually survived for 24 hours first. Today, transfer can occur very early, or conversely, where some upgrading of community hospital services has occurred, only after the birth hospital gets into trouble. What is the relationship between outcome and the need for a respirator? to antenatal complications? Who is the examiner at followup and what are the evaluation methods? Data on these points will be presented and credit given to the many individuals who participated in the care and followup of about 110 infants in this weight group cared for from 7/1/75 to 6/30/76.

Editorial: Nosocomial infection--a hazard of newborn intensive care.

Advances in infant life-support technology and a better understanding of neonatal physiology have permitted the survival of critically ill newborns who would have died a few years ago. As a result, there has been a justifiably rapid proliferation of regional intensive-care units. In this issue of the Journal, Hemming, Overall and Britt focus on an unwanted by-product of modern neonatal intensive care: nosocomial infection. During a four-year period, nosocomial infection developed in 15.3 per cent of infants hospitalized for more than 48 hours in the University of Utah Medical Center newborn intensive-care unit. Many infants had minor infections, but . . .

Pre-, peri- and postnatal prevention of major neuropediatric handicaps.

Actual preventive aspects on major neuropediatric handicaps -- particularly cerebral palsy and severe mental retardation -- are surveyed. Based on Swedish epidemiologic studies on the changing pattern through 1954--70 it has been possible to conclude that postnatal preventive measures are largely completed, and that perinatal brain damage syndromes have significantly decreased, while prenatal mechanisms now dominate and still constitute mainly unsolved problems. The study has convincingly revealed that modern neonatal intensive care does pay and has given favorable gains not only in surviving but in undamaged babies.