Very Preterm Infants Research Articles

G169 Preventing Early Postnatal Head Growth Failure in Very Preterm Infants: The Randomised Controlled SCAMP Nutrition Study

BackgroundPostnatal head growth failure is well recognised in very preterm infants (VPI), the largest deficit occurs at 3–4 weeks followed by some catch-up growth until 36weeks corrected gestational age (36wCGA)....

The Toxigen Initiative

Supplemental oxygen plays a critical role in the care of infants born at the lower limits of viability, but not without the risk of morbidity resulting from high levels or prolonged exposure. The purpose of this quality improvement project was to reduce exposure to hyperoxia as evidenced by SpO2 values within the established target range (88%-92%) among very preterm infants (VPIs) in a level 3 neonatal intensive care unit (NICU). Reducing exposure to hyperoxia in this population of exquisitely vulnerable infants has been associated with reduced morbidity, including retinopathy of prematurity, chronic lung disease, and brain injury. Two populations of interest were identified: VPIs receiving supplemental oxygen and NICU clinicians. Interventions were employed to (1) improve knowledge regarding hyperoxia and associated outcome sequelae in an interdisciplinary sample of clinicians (pretest posttest design) and (2) reinforce content of the educational intervention by triggering caregiver behaviors to reduce time the VPIs is above target SpO2 range while receiving supplemental oxygen (cohort design). : Retrospective chart review, baseline clinician knowledge assessment, education, posteducation assessment, collaborative rounds with regular feedback citing time VPIs spent above target oxygen saturation levels (SpO2), and evaluation of impact on time infants spent above target SpO2 range aligned with the project purpose. Pre- and postintervention dependent variables included clinician knowledge of hyperoxia and related evidence as measured by a 24-item multiple-choice Knowledge Assessment Tool before and after attending an educational presentation. Time VPIs were exposed to hyperoxia was evaluated using SpO2 readings and calculating the percentage of time readings were above target range before and after the introduction of educational and behavioral interventions. Outcome 1 was to increase knowledge about hyperoxia among clinician caregivers. Paired-samples t test showed a significant difference between preintervention and postintervention Knowledge Assessment Tool scores (P = .000). Outcome 2 measured reduction in time spent with SpO2 readings above target range. An independent-samples t test was used to compare outcomes in preintervention and postintervention VPI cohorts. Mean time spent with SpO2 greater than target range increased in the postintervention cohort, reaching statistical significance with P = .047. Knowledge acquisition on the subject of hyperoxia in VPIs was achieved. Decreasing the percent time VPIs were exposed to hyperoxia was not attained. The postintervention VPI cohort spent more time above the target saturation range despite greater knowledge among clinicians.

Changes in quality of life into adulthood after very preterm birth and/or very low birth weight in the Netherlands

BackgroundIt is important to know the impact of Very Preterm (VP) birth or Very Low Birth Weight (VLBW). The purpose of this study is to evaluate changes in Health-Related Quality of Life (HRQoL) of adults born VP or with a VLBW, between age 19 and age 28.MethodsThe 1983 nationwide Dutch Project On Preterm and Small for gestational age infants (POPS) cohort of 1338 VP (gestational age <32 weeks) or VLBW (<1500 g) infants, was contacted to complete online questionnaires at age 28. In total, 33.8% of eligible participants completed the Health Utilities Index (HUI3), the London Handicap Scale (LHS) and the WHOQoL-BREF. Multiple imputation was applied to correct for missing data and non-response.ResultsThe mean HUI3 and LHS scores did not change significantly from age 19 to age 28. However, after multiple imputation, a significant, though not clinically relevant, increase of 0.02 on the overall HUI3 score was found. The mean HRQoL score measured with the HUI3 increased from 0.83 at age 19 to 0.85 at age 28. The lowest score on the WHOQoL was the psychological domain (74.4).ConclusionsOverall, no important changes in HRQoL between age 19 and age 28 were found in the POPS cohort. Psychological and emotional problems stand out, from which recommendation for interventions could be derived.

1217 Sensorineural Hearing Loss After Normal Neonatal Hearing Screening in Very Preterm Infants

Background and AimTo determine the prevalence of sensorineural hearing loss (SNHL) measured by auditory brainstem response (ABR) at 2 years of corrected age in very preterm (VPT) infants with normal...

Spontaneous cries can alter the physiological well-being and cerebral oxygenation of very preterm infants

IntroductionInfant crying is a major expression of distress and can occur without any exogenous stimulation. Little is known, however, about the effects of crying on physiological homeostasis in very preterm infants (VPIs). MethodsEnvironmental, behavioral (video and audio recording) and physiologic (heart rate [HR], respiratory rate [RR], and systemic [SaO2] and regional cerebral oxygenation [rSO2]) parameters were prospectively evaluated over 10h in 18 VPIs (median gestational age, 28 [27–31] weeks). Only episodes of “spontaneous” and isolated cries were analyzed. Changes in parameters were compared over 5-second periods between baselines and 40s following the onset of crying. Two periods were distinguished: 0–20s (a) and 20–40s (b). Minimal and/or maximal values in these periods were also compared to the baseline. ResultsOf the 18 VPIs initially studied, 13 (72%) presented crying episodes (CE). They experienced 210 “spontaneous” and isolated CE, with a median of 9 [range, 1–63] CEs per child. Physiological values varied significantly from the baseline with mainly a mean decrease in HR of −4.8±5.3beats/min (b) after an initial mean increase of +2.6±2.0beats/min (a); a mean decrease in RR of −3.8±4.8cycles/min (a), followed by a mean increase of +5.6±7.3cycles/min (b) and mean unidirectional decreases in SaO2 and rSO2 (minimal values) of −1.8±2.3% and −2.5±3.0%, respectively. ConclusionSpontaneous cries can alter the homeostasis of VPIs. Their possible adverse consequences and high occurrence emphasize the need for better prevention and response to them.

Coregulated Approach to Feeding Preterm Infants With Lung Disease

Very preterm (VP) infants are at risk for poor oral feeding endurance, early cessation of eating, poor fluid management with aspiration risk, behavioral distress, and unstable heart rate (HR) and oxygenation during feeding. The study aims to determine the preliminary effectiveness of a coregulated approach (CoReg) to oral feeding for VP infants at risk for lung disease. A randomized, within-subject, cross-over design was used with 20 VP infants requiring oxygen at the start of oral feeding. Infants were bottle-fed by the Usual Care approach and by the CoReg approach on two consecutive days for an average of four feedings each. Intervention components included coregulation of suck, swallow, and breathe rhythms using enhanced auditory assessment, infant-guided feeding onsets, and infant positioning in a semielevated, side-lying position. Infant physiology metrics (HR and SaO2) were collected continuously before and during the feeding. Behavioral and auditory indicators of regulation were coded continuously from videotape during the feeding. Up to 75 feedings were analyzed (40 Usual Care and 35 CoReg) using repeated measures modeling. CoReg feedings were characterized by more frequent preparation of the infant for the feeding, were more commonly initiated in response to infant readiness cues, had more rest periods and breath regulation events, and had fewer sucking stimulation events. CoReg feedings had less SaO2 variability, decline, and time spent in a desaturated state; less HR fluctuation and decline; less behavioral disorganization; better fluid management; and less observed effort to breathe. Support is provided for an approach to feeding vulnerable infants. Enhanced auditory assessment of infant feeding rhythms increases the responsiveness of the feeder and improves infant behavioral and physiological responses.

Early single‐channel aEEG/EEG predicts outcome in very preterm infants

AimTo characterize early amplitude-integrated electroencephalogram (aEEG) and single-channel EEG (aEEG/EEG) in very preterm (VPT) infants for prediction of long-term outcome.PatientsForty-nine infants with median (range) gestational age of 25 (22–30) weeks.MethodsAmplitude-integrated electroencephalogram/EEG recorded during the first 72 h and analysed over 0–12, 12–24, 24–48 and 48–72 h, for background pattern, sleep–wake cycling, seizures, interburst intervals (IBI) and interburst percentage (IB%). In total, 2614 h of single-channel EEG examined for seizures. Survivors were assessed at 2 years corrected age with a neurological examination and Bayley Scales of Infant Development-II. Poor outcome was defined as death or survival with neurodevelopmental impairment. Good outcome was defined as survival without impairment.ResultsThirty infants had good outcome. Poor outcome (n = 19) was associated with depressed aEEG/EEG already during the first 12 h (p = 0.023), and with prolonged IBI and higher IB% at 24 h. Seizures were present in 43% of the infants and associated with intraventricular haemorrhages but not with outcome. Best predictors of poor outcome were burst-suppression pattern [76% correctly predicted; positive predictive value (PPV) 63%, negative predictive value (NPV) 91%], IBI > 6 sec (74% correctly predicted; PPV 67%, NPV 79%) and IB% > 55% at 24 h age (79% correctly predicted; PPV 72%, NPV 80%). In 35 infants with normal cerebral ultrasound during the first 3 days, outcome was correctly predicted in 82% by IB% (PPV 82%, NPV 83%).ConclusionLong-term outcome can be predicted by aEEG/EEG with 75–80% accuracy already at 24 postnatal hours in VPT infants, also in infants with no early indication of brain injury.

Corpus callosum alterations in very preterm infants: Perinatal correlates and 2year neurodevelopmental outcomes

The aim of this study was to relate altered corpus callosum (CC) integrity in 106 very preterm (VPT) infants (<30 weeks' gestational age or <1250 g birth weight) at term equivalent to perinatal predictors and neurodevelopmental outcomes at two years. T1 and diffusion magnetic resonance images were obtained. The CC was traced, and divided into six sub-regions for cross-sectional area and shape analyses. Fractional anisotropy, mean, axial and radial diffusivity were sampled within the CC, and probabilistic tractography was performed. Perinatal predictors were explored. The Bayley Scales of Infant Development (BSID-II) was administered at two years. Intraventricular hemorrhage was associated with a smaller genu and altered diffusion values within the anterior and posterior CC of VPT infants. White matter injury was associated with widespread alterations to callosal diffusion values, especially posteriorly, and radial diffusivity was particularly elevated, indicating altered myelination. Reduced CC tract volume related to lower gestational age, particularly posteriorly. Reduced posterior callosal skew was associated with postnatal corticosteroid exposure. This more circular CC was associated with delayed cognitive development. Higher diffusivity, particularly in splenium tracts, was associated with impaired motor development. This study elucidates perinatal predictors and adverse neurodevelopmental outcomes associated with altered callosal integrity in VPT infants.

High Enteral Volume Intake and Extra-Uterine Growth Restriction in Very Preterm Infants

Background and aims: Extra-uterine growth restriction is common among very preterm infants (VPI). Optimising enteral feeding is of critical importance to improve neurodevelopmental outcome. We aimed to assess the effect of a feeding regimen with a high enteral volume intake. Methods: Retrospective study of all inborn VPI (GA < 30 weeks) discharged between 2005 and 2009. Baseline clinical data and data on enteral volume intake and postnatal growth were collected. Weight was converted to standard deviation (SD; z) scores using Norwegian reference standards. Results: Eighty-six infants were included. Infants who died (14/86; 16%) had lower GA (mean (SD) 24.9 (1.5) vs. 27.4 (1.4)) than infants surviving to discharge (72/86; 84%). For all infants enteral nutrition was commenced within first 48 hours. Two infants developed surgical NEC, both survived. Daily enteral volume was 180-200 ml/kg from 3 weeks of age and onwards until self-regulation of milk intake. Fortified breast milk was used exclusively. Fortification was ceased at around weight 2500 g. Among 72 infants surviving to discharge the mean (SD) z-scores were: birth weight -0.37 (-0.27) and weight at discharge -0.42 (-0.53). The prevalence of SGA (< 10 centile) at birth (13/72; 18%) was identical to the prevalence of SGA (< 10 centile) at discharge (13/72; 18%). Conclusions: The rate of extra-uterine growth restriction was lower than previously reported in similar patient populations. We believe a high enteral volume intake is a safe method to increase energy and protein delivery and thus improve the nutritional status of very preterm infants.

Impact of Spontaneous Cries on the Physiological Well-Being and the Cerebral Oxygenation of Children Born Very Preterm

Introduction: Developmental care strategies imply to avoid any signs of discomfort or withdrawal in very preterm infant(VPI). Cries are major expressions of distress and can occur without any exogenous stimulation. Little is known about their effects on newborns' physiological homeostasis. Methods: Environmental, behavioral data (video and audio recording) and physiological data (heart and respiratory rates-HR and RR, systemic and regional cerebral oxygenations-SaO2 and rSO2) were prospectively collected during 10 hours in 18 VPI (median gestational age-GA, 28 [27-31] weeks). Only episodes of “spontaneous” cries were analysed. Changes in parameters were compared over 5 seconds periods between baseline and the 40 seconds following the beginning of cry. Results: A total of 13(72%) VPIs have presented 210 episodes of “spontaneous” cries, with a median number of 9 [0-63] cries per child during the study period. Physiological values varied significantly: a decreased mean HR (- 4.8 beats/min +/− 5.3: p < 0.01), which despite an increased mean RR (+ 5.6 cycles/min +/− 7.3: p < 0.05) results in a decreased mean SaO2 (- 1.8% +/− 2.3: p < 0.05) associated with a decreased mean rSO2 (- 2.5% +/− 3: p <0.05). No significant effects of GA or of the intensity of crying on the responses were observed. Conclusion: Spontaneous cries can alter the homeostasis of VPIs. Their frequent occurrences and their possible adverse consequences underline the need for a better observation of VPIs' behaviour and an adequate answer to them, which both could benefit from individualized developmental care strategies.

The Impact of Neonatal Morbidities on Smooth Pursuit Eye Movements in Very Preterm Infants

Background: Infants born very preterm (VPT) i.e.< 32w gestational age (GA) have increased risk of developing impaired visual perception. Previously we have found that visual motion perception in VPT infants, evaluated by smooth pursuit eye movements (SP) was significantly reduced at both 2 and 4 months corrected age (CA) compared to term infants. SP are essential for perception of the moving environment in daily life.

Neonatal respiratory dysfunction and neuropsychological performance at the preschool age: A study of very preterm infants with bronchopulmonary dysplasia.

The neuropsychological outcome of chronic lung disease (CLD) in the very preterm (VP) infant may be determined by a process involving chronic hypoxia, with superimposed acute hypoxic episodes, in the developing brain. We wished to study the differences in quality of outcome between VP preschoolers with and without history of the most common form of CLD in the preterm infant, bronchopulmonary dysplasia (BPD). We also examined the strength of association between BPD severity and neuropsychological outcome, with degree of severity defined according to the National Institute of Child Health and Human Development (NICHD) National Heart, Lung and Blood Institute (NHLBI) Workshop categorical ranking scheme (Jobe & Bancalari, 2001) or in accord with dimensional views of severity of respiratory illness. We evaluated the intellectual, language, and motor outcomes of 156, predominantly middle-class preschoolers with history of VP birth, with (n = 80) or without (n = 76) BPD. We used supplemental oxygen requirement or need for mechanical ventilation as indirect indexes of respiratory dysfunction. Following adjustment for potentially confounding sociodemographic variables and perinatal medical risk factors, we found no group differences in neuropsychological outcome based on categorical ranking of BPD severity. However, continuous measures of BPD severity accounted for a unique portion of the variance in fine motor performance (η²p = .05), while patent ductus arteriosus, a risk marker or antecedent of BPD, explained a unique portion of the variance in both receptive language (η²p = .048), and gross motor (η²p = .061) function. A significant, yet circumscribed, association was demonstrated between neonatal hypoxic risk, in the VP infant, and neuropsychological outcome assessed in the preschool years.

Allergic diseases among very preterm infants according to nutrition after hospital discharge

To determine whether a cow's milk-based human milk fortifier (HMF) added to mother's milk while breastfeeding or a cow's milk-based preterm formula compared to exclusively mother's milk after hospital discharge, increases the incidence of developing allergic diseases among very preterm infants (VPI) during the first year of life. Of a cohort of 324 VPI (gestational age 24-32 wk), the exclusively breastfed VPI were shortly before discharge randomized to breastfeeding without fortification or supplementing with a fortifier. Those not breastfed were fed a preterm formula. The intervention period was from discharge until 4 months corrected age (CA). Follow-up was performed at 4 and 12 months CA including specific IgE to a panel of allergens at 4 months CA. The incidence during and prevalence at 12 months CA of recurrent wheezing (RW) was 39.2% and 32.7%, while atopic dermatitis (AD) was 18.0% and 12.1%, respectively. Predisposition to allergic disease increased the risk of developing AD (p=0.04) [OR 2.6 (95% CI 1.0-6.4)] and the risk of developing RW (p=0.02) [OR 2.7 (95% CI 1.2-6.3)]. Boys had an increased risk of developing RW (p=0.003) [OR 3.1 (95% CI 1.5-6.5)]. No difference was found between nutrition groups. None developed food allergy. Compared to exclusively breastfed, VPI supplemented with HMF or fed exclusively a preterm formula for 4 months did not have an increased risk of developing allergic diseases during the first year of life.

Intérêt du sulfate de magnésium dans la prévention de la paralysie cérébrale de l’enfant né prématuré

This review concentrates on best evidence emerging in recent years on cerebral palsy prevention by administration of magnesium sulphate in mothers being at risk of preterm birth before 33–34 weeks’ gestation. It has been shown in the Cochrane database and in three meta-analysis of five randomised trials (Magpie Trial [neuroprotection of the preeclamptic mother], MagNet [neuroprotection/other intent: tocolysis], ACTOMgSO4 [neuroprotection], PRE-MAG [neuroprotection] and BEAM [neuroprotection]) that prenatal low-dose of magnesium sulphate given to mothers at risk of preterm birth has no severe deleterious effects in mothers and does not increase paediatric mortality in verypreterm infants. Moreover, it has a significant neuroprotective effects on occurrence of cerebral palsy at two years of age (with a 0.69 relative risk and a 95% confidence interval 0.54–0.87) and, in the neuroprotection subgroup, on the combined outcome of pediatric mortality or cerebral palsy (with a 0.85 relative risk and a 95% confidence interval: 0.74–0.98). The number needed to treat (NNT) to prevent one case of cerebral palsy was 63 (95% CI: 39 to 172) and the NNT for an extra survivor free of cerebral palsy in the neuroprotection subgroup was 41 (95% CI: 22 to 357), justifying that magnesium sulphate should be discussed as a stand-alone treatment or as part of a combination treatment.

Perinatal Regionalization for Very Low-Birth-Weight and Very Preterm Infants

For more than 30 years, guidelines for perinatal regionalization have recommended that very low-birth-weight (VLBW) infants be born at highly specialized hospitals, most commonly designated as level III hospitals. Despite these recommendations, some regions continue to have large percentages of VLBW infants born in lower-level hospitals. To evaluate published data on associations between hospital level at birth and neonatal or predischarge mortality for VLBW and very preterm (VPT) infants. Systematic search of published literature (1976-May 2010) in MEDLINE, CINAHL, EMBASE, and PubMed databases and manual searches of reference lists. Forty-one publications met a priori inclusion criteria (randomized controlled trial, cohort, and case-control studies measuring neonatal or predischarge mortality among live-born infants < or = 1500 g or < or = 32 weeks' gestation delivered at a level III vs lower-level facility). Paired reviewers independently assessed publications for inclusion and extracted data using standardized forms. Discrepancies were decided by a third reviewer. Publications were reviewed for quality by 3 authors based on 2 content areas: adjustment for confounding and description of hospital levels. We calculated weighted, combined odds ratios (ORs) using a random-effects model and comparative unadjusted pooled mortality rates. We observed increased odds of death for VLBW infants (38% vs 23%; adjusted OR, 1.62; 95% confidence interval [CI], 1.44-1.83) and VPT infants (15% vs 17%; adjusted OR, 1.55; 95% CI, 1.21-1.98) born outside of level III hospitals. Consistent results were obtained when restricted to higher-quality evidence (mortality in VLBW infants, 36% vs 21%; adjusted OR, 1.60; 95% CI, 1.33-1.92 and in VPT infants, 7% vs 12%; adjusted OR, 1.42; 95% CI, 1.06-1.88) and infants weighing less than 1000 g (59% vs 32%; adjusted OR, 1.80; 95% CI, 1.31-2.46). No significant differences were found through subgroup analysis of study characteristics. Meta-regression by year of publication did not reveal a change over time (slope, 0.00; P = .87). For VLBW and VPT infants, birth outside of a level III hospital is significantly associated with increased likelihood of neonatal or predischarge death.

Factors associated with successful establishment of breastfeeding in very preterm infants

To describe feeding practices at hospital discharge in relation to characteristics of the very preterm infants (VPI) and their mothers. Design. Prospective hospital-based registration of very preterm infants born with a gestational age < or =32 weeks in Denmark during 2004-2008. Subjects. Healthy mothers and VPI without diseases causing eating disabilities at discharge. A total of 478 VPI were registered. At discharge, 60% were exclusively breastfed, 35% were exclusively bottlefed, and 5% were both breast- and bottle-fed. Mothers of high social class (p = 0.000) and 'not smoking' (p = 0.003) were significantly more often breastfeeding their preterm infant(s) at discharge. Single births infants tended more often to be breastfed (p = 0.09). Infant age at discharge and duration of hospitalization did not influence breastfeeding at discharge. Increase in weight z-score from birth to discharge was largest in the bottlefeeding-group compared with the breastfeeding-group (p = 0.000) probably as a result of feeding practice the last week(s) of hospitalization. Breastfeeding can successfully be established in very preterm infants. Mothers of low social classes, smokers, multiple birth and very preterm infants with low weight for age may need extra attention in breastfeeding establishing policies.

Motor performance in very preterm infants before and after implementation of the newborn individualized developmental care and assessment programme in a neonatal intensive care unit

To compare motor performance in supine position at the age of 4-months corrected age (CA) in very preterm (VPT) infants cared for in a neonatal intensive care unit (NICU) before and after the implementation of the Newborn Individualized Developmental Care and Assessment Program (NIDCAP). Assessments of motor performance in supine position according to level of motor development and quality of motor performance were made, using the Structured Observation of Motor Performance in Infants (SOMP-I). VPT infants cared for in a NICU at a Swedish university hospital before, Group A (n = 68), and after, Group B (n = 58), the implementation of developmentally supportive care based on NIDCAP. The infants who were treated after the introduction of NIDCAP showed higher level of motor development in the arms/hands and trunk. No significant group differences were noted in total deviation score for the respective limbs, but lower frequency of lateral flexion in head movements, extension-external rotation-abduction, extension-internal rotation-adduction and varus and valgus position in the feet was found in the NIDCAP group, compared with those treated before the introduction. The infants who were treated after NIDCAP care had been implemented showed a higher level of motor development in arms/hand and trunk and fewer deviations in head, legs and feet at 4-months CA than infants treated before NIDCAP implementation. The observed changes may be due to NIDCAP and/or improved perinatal and neonatal care during the studied time period.

Est-il possible de protéger le cerveau de l’enfant né prématuré et de diminuer le taux de séquelles neuro-développementales ?

With improving neonatal survival for very premature babies, the challenge for neonatalogists is to ameliorate outcome of surviving babies. Several pharmacological molecules have been shown to have protective effects in different types of in vitro or in vivo animal models of acquired cerebral brain damages. However translational research and conduction of therapeutic trials in human remain difficult due to failure to recognize start of deleterious cascade leading to cerebral damage and additional toxic effect of potential protective molecules. This review concentrates on best evidence emerging in recent years on prevention on brain damage by early drug administration. It has been shown in two randomised trials that prenatal low-dose of magnesium sulphate does not increase paediatric mortality in very-preterm infants and has non significant neuroprotective effects on occurrence of motor dysfunction (with a 0.62 odds ratio in the French trial Premag and 0.71 relative risk in the Australian trial ACTOMgSO4), justifying that magnesium sulphate should be discussed as a stand-alone treatment or as part of a combination treatment, at least in the context of clinical trials. Antenatal corticosteroid therapy increases the survival of very-preterm infants, including the most immature. Moreover in an observational recent study of the Epipage cohort, it has been observed a significant decrease in white matter injury in the 28-32 weeks' gestation group but no effect on long term outcome and behaviour. Conversely in the most immature of the 24-27 weeks' gestation group, no effect has been detected either in white matter injury incidence or in long term outcome rates. Caffeine has a protective effect since a decrease in cerebral palsy has been noted in the caffeine group in a randomised trial studying caffeine versus placebo. For what concern other widely used potential protective molecules during the perinatal period, there is no evidence of cerebral protection with indometacine, nitric oxide, eythropoietin, phenobarbital, and etamsylate. Due to their specific properties, a careful evaluation of aspirin, anaesthetic drugs and tocolytics should be done in the next months.

Effet du sulfate de magnésium sur la mortalité et la morbidité neurologique chez le prématuré de moins de 33 semaines, avec recul à deux ans : résultats de l’essai prospectif multicentrique contre placebo PREMAG

Objective To evaluate whether magnesium sulphate (MgSO 4) given to women at risk of very-preterm birth would be neuroprotective in preterm newborns. Patients and methods In 18 French centres, women with fetuses of gestational age less than 33 weeks whose birth was expected within 24 hours were randomised from 1993 to 2003 with follow-up of infants until two years of age after discharge. They received a single injection of 0.1 mg/l de MgSO 4 (4 g) or isotonic 0.9% saline over 30 minutes. This study is registered as an International Standard Randomised Controlled Trial, number 00120588. Analyses were based on intention to treat. Results Data from 688 infants were analysed of which 606 were followed up and 10 were lost to follow-up. Comparing infants who received MgSO 4 or placebo, respectively, has shown a decrease of all primary endpoints (total mortality, severe white matter injury and their combined outcome) and of all secondary endpoints (motor dysfunction, cerebral palsy, cognitive dysfunction and their combined outcomes at two years of age) in the MgSO 4 group. The decrease was nearly significant or significant for gross motor dysfunction (OR: 0.65 [0.41–1.02]) and combined criteria: death and cerebral palsy (OR: 0.65 [0.42–1.03]); death and gross motor dysfunction (OR: 0.62 [0.41–0.93]); death, cerebral palsy and cognitive dysfunction (OR: 0.68 [0.47–1.00]). No major maternal adverse effects were observed in the MgSO 4 group. Discussion and conclusion Given its beneficial effects and safety, the use of prenatal low-dose MgSO 4 for preventing neurodisabilities of very-preterm infants should be discussed either as a stand-alone treatment or as part of a combination treatment, at least in the context of clinical trials.

Developmental assessment of preterm infants at 2 years: validity of parent reports

Parental questionnaires are inexpensive alternatives to standardized testing for outcome measurement. The Parent Report of Children's Abilities has previously been revised (PARCA-R) and validated for use with very-preterm infants at 2 years of age. This study revalidated the PARCA-R for assessing cognition in a larger and more inclusive sample of preterm infants. One hundred and sixty-four children (82 males, 82 females) of <32 weeks' gestation (median 29wks, interquartile range [IQR] 28-30wks); and median birthweight 1200g (IQR 925-1463g) were evaluated using the Mental Development Index (MDI) of the Bayley Scales of Infant Development - 2nd edition (BSID-II) at 2 years' corrected age. Parents completed the PARCA-R questionnaire. Significant correlations between PARCA-R Parent Report Composite (PRC) scores and MDI scores (r=0.77, 95% confidence interval [CI] 0.69-0.82, p<0.01) demonstrated concurrent validity. A receiver operating characteristic-determined PRC cut-off of <44 had optimal discriminatory power (area under curve 0.92) for identifying MDI <70, with 85% sensitivity (95% CI 0.58-0.96), 87% specificity (95% CI 0.81-0.92), 98% negative predictive value (95% CI 0.95-1), and 37% positive predictive value (95% CI 0.22-0.54). The PARCA-R has good concurrent validity and diagnostic utility for identifying cognitive delay in very-preterm infants at 2 years of age. It is useful for outcome measurement, developmental screening, and facilitating parental involvement at follow-up.