Severe IVH Research Articles

243 EXTREMELY LOW BIRTKWEIGHT INFANTS; PREDICTION OF OUTCOME AT 5 YEARS

Improved prenatal and neonatal care have contributed to the increased survival of VLBW. The tiny infants, however, have an increased risk of later sequaleae, such as cerebral plasy, retinopathy, schoold difficulties and chronic lung disease. These sequaleae are a great concern for both the parents and the society. The purpose of this study was to analyse the neonalal risk factors to these problems in extremely low birthweight (<1000 g) infants.During the period 1982-1987 96 (56%) ELBWI survived at the NICU of Children's Hospital. University of Helsinki. At five years of age all children underwent neuropsychological testing and a neurological investigation. The data about the neonatal period were collected retrospectively. They included the social background of the family, duration of the pregnancy and birthweight, several parameters from the first day of life and from the NICU treatment.The CRIB score was calculated from these data to all infants. Cranial ultrasound examination was performed several times to all infants.Of the infants 11 % had neurological abnormalities, 16% had retinopathy, 19% had emotional disturbances, 17% had delayed verbal development, 32% had visuomotor abnormalities and 20% had slight to severe intellectual impairment. All these aspect were normal in 53% of the infants. Intellectual impairment was associated with low gestational age, low birthweight, long respirator care, long oxygen demand, sepsis during the NICU care, severe IVH, and also with high CRIB score. Logistic regression analysis indicates that sepsis and third grade IVH were most important of these. Other outcome variables showed similar associations. However, neurological abnormalities were associated only with severe, fourth grade IVH.

Risk factors for early intraventricular hemorrhage in low birth weight infants

Because earlier studies suggested that preterm infants with germinal matrix hemorrhage or intraventricular hemorrhage or both (GMH/IVH) present within the first 12 postnatal hours are at greatest risk for the development of high-grade hemorrhage and neurodevelopmental disability, we examined the risk factors for this insult among 229 neonates of 600 to 1250 gm birth weight in a multicenter study. All had echoencephalography (ECHO) within the first 11 hours and serially for the next 20 days; risk factor data were collected prospectively. Forty-three infants had GMH/IVH within the first 5 to 11 hours (mean age at ECHO 7.7 hours): 18 GMH and 21 grade II, 1 grade III, and 3 grade IV IVH. One hundred eighty-six infants did not have GMH/IVH at a mean age of 7.9 hours. Both groups of infants were similar in birth weight, gestational age, maternal risk factors, cord pH values, and surfactant therapy before ECHO. The group with early IVH had more vertex presentations than the group without early IVH (79% vs 55%, p = 0.043), less maternal tocolytic use (42% vs 60%, p = 0.029), and more vaginal deliveries (67% vs 44%, p = 0.005). In the first 21 days, severe IVH developed in 12 infants with early IVH and in 6 infants without early IVH (p < 0.001). There were more neonatal deaths (16% vs 6%, p = 0.035) and more deaths at any time during the primary hospitalization (23% vs 9%, p = 0.010) among the early IVH group than among the group without early IVH. Multivariate analysis indicated that the mode of delivery, fetal presentation, and birth weight were important and independent prognostic indicators of IVH.

1341 VISUAL INFORMATION PROCESSING IN INFANTS WITH INTRAVENTRICULAR HEMORRHAGE (IVH)

We assessed visual attention in an habituation/recovery paradigm and performance on the Bayley Scales of Infant Development in the second year of life among twelve patients who suffered moderate (Grades II-III) or severe (Grade IV) IVH, either unilateral or bilateral.Test results showed that patients with unilateral bleed had greater habituation to a redundant stimulus, indicating more efficient information processing. Recovery of attention to a novel stimulus appeared to be related to the severity, rather than the laterality, of the IVH. As measured by the Bayley Psychomotor Index (PDI), patients with unilateral bleeds performed better than those with bilateral involvement (mean 85 vs 66). The PDI was unaffected by the grade of IVH. The Bayley Mental Development Index (MDI) was affected by severity level, with higher IVH grades showing poorer performance (mean 71 vs 56).The results of the study support the hypothesis that unilateral hemorrhage results in a more optimal development than a bilateral one, and this may be independent of the grade of the bleed.

1493 THE EFFICACY OF CHEST PHYSIOTHERAPY (CPT) ON THE FIRST POSTNATAL DAY IN INFANTS WITH RDS

To study the efficacy of CPT (vibration, percussion and suction) on the first postnatal day, 20 infants (mean±S.D. B.W. 1.2±0.4 kg, G.A. 30±2 wks, Postn. A. 4.9±3.5 hr) with RDS and on asst. vent. shortly after birth were randomly assigned to two grs. Gr. I (10) with CPT, Gr. II (10) ET suction only. CPT or suction were performed every 2 hrs. Vibration and percussion were performed for 15 seconds in 4 different postures, followed by ET suction. The parameters evaluated included: blood gases, pH, mean airway pressure (MAP), ET secretion, incidence of air leaks, IVH, PDA. Infants in Gr I had sign. (p<0.05) lower MAP than Gr II at 16 hrs. The blood gases and pH were comparable. There was no sign. difference between the groups in ET secretions per suction at 0-8, 8-16 and 16-24 hrs (Gr I 0.1±0.1, 0.1±0.1, 0.1±0.1 gm vs Gr II 0.1±0.2, 0.1±0.1, 0.1+±0.1 gm respectively) and in incidence of air leaks (2/10 vs 3/10), IVH (7/10 vs 3/10), PDA (4/10 vs 5/10) and duration of O2 and IMV therapy. However, Gr I infants had sign. (p<0.05) higher incidence (5/10) of severe IVH (≥Grade II) than Gr II (0/10). We conclude that vibration and percussion are not beneficial and may be detrimental during the first postnatal day.

CAN ULTRASOUND PREDICT DEVELOPMENTAL OUTCOME IN INFANTS WITH GRADE III IV IVH?

We studied the usefulness of realtime ultrasound scan (US) in predicting developmental outcome in infants with Grade III and IV IVH. US were done prior to discharge from NICU in the coronal plane only. Infants were classified into 5 groups depending on size of ventricles, visible dilated temporal horns and asymmetry in size of ventricles or presence of porencephalic cysts. Developmental assessment was made using Denver Developmental and Bayley Scales of Infant Assessment. 36 infants were studied.The mean birthweight of the infants is 1240±498gms. and gestational age is 29.1 weeks (range 24 to 40). The mean postnatal age at follow-up is 16.25±7.7 months. All infants with a DQ > 85 are considered normal, 75-85 suspicious and <75 abnormal. Statistically significant differences are noted in the DQ between infants in the classes of A and B to infants in the classes of D and F (P= <.001). Our results indicate that US scans done prior to discharge are useful in predicting developmental outcome in infants with severe IVH using our classification.

BRAINSTEM AUDITORY EVOKED RESPONSES(BAER)IN PREMATURE INFANTS WITH SEVERE INTRAVENTRICULAR HEMORRHAGE (IVH)

Higher incidence of BAER abnormalities were found in a group of very low birthweight infants with severe IVH compared to a heavier group without IVH.Nineteen infants (BW:1.2±0.3kg,GA:28±1 wk) with IVH and 42 (BW:2.3±1.2kg,GA:36±4wks) control infants were examined at post-conceptual age ranging from 33 to 52 weeks. Monaural stimulation at 16 clicks per second and 70 decibel intensity was used and the presence, stability, and appearance of Waves I, III, and V were evaluated.Six of 19 IVH (32%) and 1 of 42 control (2%) infants manifest BAER abnormalities. This difference was significant at the p<0.02 level. In the IVH group, 3 of 8 infants with ventricular dilatation (Grade 3) and 3 of 11 infants with intracerebral hemorrhage (Grade 4) had abnormal responses.Seizures, asphyxia, and male sex significantly correlated with the presence of abnormal wave forms. However, these factors lost their significance when the analysis of variance was corrected for the presence of IVH.In this group of infants, severe intraventricular hemorrhage is the most important etiology for the existence of brainstem dysfunction as measured by BAER.