Background

Small for gestational age (SGA) infants have been reported to be at higher risk for sudden infant death syndrome (SIDS).

Objective

To compare the risk of SIDS among SGA and large for gestational age (LGA) infants with that of death from other causes of sudden unexpected deaths in infancy (SUDI) and the residual “other” causes of infant death.

Methods

The 2002 US period infant birth and death certificate linked file was used to identify infant deaths classified as SIDS (ICD‐10 code R95), SUDI (ICD‐10 codes R00‐Y84 excluding R95) or all other residual codes. The 2002 race and sex‐specific birth cohorts were used to generate the 10th and 90th percentiles of birth weight for each gestational age week from 24 to 42 weeks' gestation. Demographic variables previously identified as associated with SIDS were used in multiple logistic regression equations to determine the risk for death among SGA and LGA infants (birth weight <10th percentile and >90th percentile, respectively) independent of other potentially confounding variables.

Results

Complete data on 1956 SIDS deaths, 2012 SUDI, and 11 592 other deaths were available. The adjusted OR for SIDS, SUDI and “other” causes for SGA infants was 1.65 (95% CI 1.47 to 1.85), 1.78 (1.59 to 2.00) and 4.68 (4.49 to 4.88), respectively. The adjusted OR for LGA infants was reduced for SIDS (0.73 (0.60 to 0.89)), SUDI (0.81 (0.68 to 0.98)) and “other” (0.42 (0.38 to 0.46)).

Conclusion

Although SGA infants seem to be at slightly increased risk for SIDS or SUDI their risk for “other” residual causes is about 2.5 times higher. LGA infants seem to be at reduced risk of mortality for all causes. The mechanisms by which restricted intrauterine growth increases risk of mortality and excessive intrauterine growth offers protective effects are uncertain.

Perspective on the review by Bose and Laughon (see page 498)

Perspective on the paper by Glazebrook et alsee page 438

Perspective on the paper by Malloy (see page 473)

Analysis of paired arterial and venous specimens can give insights into the aetiology of acidosis in the newborn

Understanding of the specific pathophysiology of acquired brain injury in infants with CHD will help optimise treatment and brain protection strategies

Objective

To evaluate the influence of parenting intervention on maternal responsiveness and infant neurobehavioural development following a very premature birth.

Design

Cluster‐randomised controlled trial, with a crossover design and three‐month washout period.

Setting

Six neonatal intensive care units.

Patients

Infants born <32 weeks' gestation.

Intervention

The Parent Baby Interaction Programme (PBIP) is a supportive, educational intervention delivered by research nurses in the neonatal intensive care unit, with optional home follow‐up for up to six weeks after discharge.

Main outcome measures

Parenting stress at 3 months adjusted age, as measured by the Parenting Stress Index (PSI). Other outcomes included the Neurobehavioural Assessment of the Preterm Infant (NAPI) and maternal interaction as assessed by the Nursing Child Assessment Teaching Scale (NCATS) and the responsivity subscale for Home Observation for Measurement of the Environment (HOME).

Results

112 infants were recruited in the intervention phases and 121 in the control phases. Mean standardised NAPI scores at 35 weeks did not differ between the PBIP and control groups. Both groups had low but similar NCATS caregiver scores before discharge (36.6 in the PBIP group and 37.4 in control, adjusted mean difference −0.7, 95% CI −2.7 to 1.4). At three months, adjusted age mean PSI scores for the PBIP group were 71.9 compared with 67.1 for controls (adjusted mean difference 3.8, 95% CI −4.7 to 12.4). NCATS scores and HOME responsivity scores were similarly distributed between the groups.

Conclusion

This early, nurse‐delivered, parent‐focused interaction programme intervention had no measurable effects on short‐term infant neurobehavioural function, mother–child interaction or parenting stresses.

Background

Positive pressure ventilation in premature infants can improve oxygenation but may diminish cerebral blood flow and cardiac output. Low superior vena cava (SVC) flow increases risk of intraventricular haemorrhage, and higher mean airway pressure is associated with low SVC flow. Whether this is a direct effect of positive pressure ventilation or a reflection of severity of lung disease is not known. This study aimed to determine if positive end expiratory pressure (PEEP) in ventilated newborns could be increased without clinically relevant cardiorespiratory changes.

Method

Ventilated newborns were studied before and 10 min after increasing PEEP (5 cm H2O to 8 cmH2O) and again when PEEP returned to baseline. Echocardiographic and respiratory function measurements were collected during the intervention.

Results

In 50 infants, increased PEEP was associated with a non‐significant difference in mean SVC flow of −5 ml/kg/min (95% CI −12 to 3 ml/kg/min) but a significant reduction in right ventricular output of 17 ml/kg/min (95% CI 5 to 28 ml/kg/min). The increase in lung compliance was non‐significant (median difference 0.02 ml/cmH2O/kg) and the decrease in lung resistance (18 cmH2O/l/s; 95% CI 10 to 26 cm H2O/l/s) was significant. Changes (%) in lung compliance and SVC flow, when corrected for Paco2, were positively associated (regression coefficient 0.4%; 95% CI 0.2% to 0.6%).

Conclusion

A short‐term increase in PEEP does not lead to significant changes in systemic blood flow, although 36% of infants in the present study had clinically important changes in flow (±25%). The intervention can improve dynamic lung function, especially airway resistance. Improvements in compliance tend to be associated with improvements in blood flow.

Objective

To investigate whether preterm newborns who are small for gestational age are at increased risk of nosocomial infections and necrotising enterocolitis.

Design, setting and subjects

The German national surveillance system for nosocomial infection in very low birthweight infants uses the US Centers for Disease Control and Prevention criteria. 2918 newborns (24–28 weeks), born between 2000 and 2004, were selected after application of predefined inclusion criteria to ensure similar proportions of small and appropriate weight for gestational age newborns across gestational age groups.

Main outcome measures

The outcome criterion was at least one episode of nosocomial sepsis, pneumonia or necrotising enterocolitis. Adjusted odds ratios and corresponding 95% CIs were calculated based on general estimating equation models.

Results

The study population consisted of 13% (n = 392) small and 87% (n = 2526) appropriate weight for gestational age infants. 33% (n = 950) of the infants experienced at least one episode of sepsis: 42% (n = 163) of small and 31% (n = 787) of appropriate weight for gestational age newborns (adjusted OR 1.41, 95% CI 1.05 to 1.89). Pneumonia was diagnosed in 6% (n = 171) of infants: 8.4% (n = 33) of small and 5.5% (n = 138) of appropriate weight for gestational age newborns (adjusted OR 1.57, 95% CI 1.19 to 5.57). Necrotising enterocolitis was documented in 5.2% (n = 152) of infants: 7.1% (n = 28) of small and 4.9% of (n = 124) appropriate weight for gestational age newborns (adjusted OR 1.20, 95% confidence interval 0.75 to 1.94).

Conclusions

Growth‐retarded preterm infants seem to be at increased risk of nosocomial infection, irrespective of the responsible pathogen. Future immunological research should elucidate potential causal associations.

Objectives

To evaluate the impact of selective fluconazole prophylaxis on incidence of invasive fungal infection and emergence of fluconazole resistance in neonatal intensive care.

Design

Retrospective study of very low birthweight (VLBW) babies (<1500 g birth weight) admitted to a neonatal intensive care unit (NICU) in the period 1 year before and after the implementation of an antifungal prophylaxis guideline.

Patients

VLBW babies with an additional risk factor: colonisation of Candida species from surface sites with a central venous catheter; third generation cephalosporin treatment; or total duration of antibiotic treatment >10 days.

Fluconazole protocol

Fluconazole 6 mg/kg for 3 weeks. Dose interval is every 72 h during the first 2 weeks of life. Thereafter, dose interval is reduced to every 48 h until 3 weeks old when daily fluconazole is given. Fluconazole is administered orally when enteral feeding achieved.

Results

121 and 107 VLBW babies were admitted to the NICU in the year before and after the guideline was implemented, respectively. Data were available in 110 and 102 charts. 33/110 and 31/102 babies were eligible for fluconazole prophylaxis in the period before and after guideline implementation. 6/33 babies eligible for prophylaxis developed culture proven Candida sepsis before compared with no (0/31) babies after the guideline was implemented (p = 0.03). One baby (1/31) did develop probable Candida sepsis in the post guideline implementation period. During both study periods all Candida isolates remained fully susceptible to fluconazole.

Conclusions

Selective antifungal prophylaxis has reduced invasive fungal sepsis in one NICU without evidence of fluconazole resistance emerging.

Objective

With changes in the predominant pathogenic factors in the new form of bronchopulmonary dysplasia (BPD), a different pattern of CT findings may be expected. This study aimed to (1) describe CT findings in infants with BPD and (2) correlate the CT findings with lung function abnormalities.

Study design and method

Retrospective review of 41 very low birthweight infants with BPD, who were referred for pulmonary investigations at between 10 and 20 months after birth because of persistent respiratory symptoms, and underwent CT and lung function tests.

Results

None of the infants had normal CT findings. The most frequent abnormalities were hyperlucent areas (n = 36; 88%), linear opacities (n = 39; 95%), and triangular subpleural opacities (n = 26; 63%). Bronchiectasis was not seen. None of the CT abnormalities correlated with the maximum expiratory flow at functional residual capacity (VmaxFRC). In contrast, increased number of subpleural opacities and limited linear opacities were associated with low FRC and longer duration of neonatal oxygen exposure. The numbers of triangular subpleural opacities also correlated with duration of mechanical ventilation.

Conclusions

Despite advances in neonatal care, many CT findings in infants with BPD are similar to those observed in the pre‐surfactant era, and are still associated with duration of supplemental oxygen and mechanical ventilation. The absence of bronchial involvement in the present study was the most striking difference from previous studies.

Objective

Use of video recordings of newborn infants to determine: (1) if clinicians agreed whether infants were pink; and (2) the pulse oximeter oxygen saturation (Spo2) at which infants first looked pink.

Methods

Selected clips from video recordings of infants taken immediately after delivery were shown to medical and nursing staff. The infants received varying degrees of resuscitation (including none) and were monitored with pulse oximetry. The oximeter readings were obscured to observers but known to the investigators. A timer was visible and the sound was inaudible. The observers were asked to indicate whether each infant was pink at the beginning, became pink during the clip, or was never pink. If adjudged to turn pink during the clip, observers recorded the time this occurred and the corresponding Spo2 was determined.

Results

27 clinicians assessed videos of 20 infants (mean (SD) gestation 31(4) weeks). One infant (5%) was perceived to be pink by all observers. The number of clinicians who thought each of the remaining 19 infants were never pink varied from 1 (4%) to 22 (81%). Observers determined the 10 infants with a maximum Spo2 ⩾95% never pink on 17% (46/270) of occasions. The Spo2 at which individual infants were perceived to turn pink varied from 10% to 100%.

Conclusion

Among clinicians observing the same videos there was disagreement about whether newborn infants looked pink with wide variation in the Spo2 when they were considered to become pink.

Objectives

To monitor preterm infants in a cot and a car seat and compare an observed car seat trial with polysomnography (PSG).

Design

Non‐randomised controlled trial.

Setting

Regional neonatal unit.

Patients

Preterm infants before discharge.

Interventions

Nap PSG respiratory and sleep variables were measured including gastro‐oesophageal pH. Nurse observations included respiratory distress, apnoea measured by apnoea alarm, oxygen saturation and heart rate. Infants were studied supine in a cot and then in a car seat. Nursing observations were compared with PSG during the car seat trial only. Criteria for failure of the PSG and observed tests were predefined.

Main outcome measures

Difference in respiratory instability between cot and car seat. Concurrence regarding failure of the car seat trial between nurse‐observed data and PSG.

Results

20 infants (median gestation 33 weeks (range 28–35 weeks; median postmenstrual age (PMA) at study 36.5 weeks (range 35–38 weeks)) were studied. There were sufficient car seat data on 18 infants for comparison. There were fewer central apnoeas and arousals in the cot than the car seat (p = 0.047 and p = 0.024, respectively). Airway obstruction was not more common in the car seat. Younger PMA at time of study predicted failure in both car seat (p = 0.022) and cot (p = 0.022). The nurse‐observed test had low sensitivity for predicting PSG failure but more accurately predicted airway obstruction on PSG.

Conclusions

Immature infants exhibit respiratory instability in cots and car seats. A car seat test does not accurately detect all adverse events during sleep in the seat.

Background

It has been hypothesised that cerebral palsy (CP) and other congenital anomalies are attributable to feto–fetal transfusion problems in a monochorionic multiple gestation. Thus more than one organ could be compromised leading to the coexistence of two or more anomalies in a fetus. Such anomalies in a singleton birth may be attributable to early demise of the co‐conceptus as a vanishing twin.

Aim

To determine whether the coexistence of congenital anomalies and CP is greater than a chance finding by comparing the prevalence of congenital anomalies in children with CP with that in the general population of children.

Methods

A population‐based register of children with CP born in 1966–1991 in the counties of Merseyside and Cheshire, UK, comprised the index population. Coexisting congenital anomalies were recorded. For comparison the population prevalence of congenital anomalies was obtained from eight congenital malformation registers in the UK.

Results

Children with CP were found to have highly significant increases in risk for microcephaly, isolated hydrocephaly, congenital anomalies of the eye, congenital cardiac anomalies, cleft lip and/or palate and congenital dislocation of the hips and talipes (p<0.001) and atresias of the oesophagus (p<0.001) and intestines (p<0.01). The relative risks ranged from 3.1 (95% CI 1.9 to 4.8; p<0.001) for congenital malformations of the cardiac septa to 116.09 (95% CI 84.0 to 162.3; p<0.001) for microcephaly.

Conclusions

Congenital anomalies in children with CP are found much more frequently than expected by chance. A common pathogenic mechanism may account for the coexistence of disparate congenital anomalies. A hypothesis is proposed for such a common pathogenic mechanism.

Objective

To assess growth patterns of 9‐year‐old children, some of whom had intrauterine growth restriction (IUGR).

Method

75 9‐year‐old children (41 were IUGR infants) were weighed and measured at birth, at 1 year, at 2 years and at 9 years of age. Using general linear models for continuous data, changes in weight z scores were used to quantify growth rate between birth and 9 years of age.

Results

IUGR children were smaller at birth (weight z score –2.1 v 0.2 in normal children; p<0.001) but showed a greater increase in their weight between birth and 9 years (change of weight z score 1.5 v 0.4 in normal children; p = 0.001). At the age of 9 years the weight, height and body mass index (BMI) z scores were lower in IUGR children than the control children (weight z score –0.4 v 0.6, respectively; p<0.001, height z score –0.5 v 0, respectively; p = 0.002, BMI z score −0.2 v 0.7, respectively; p = 0.002). The predictors of these differences were IUGR, birth weight and maternal and paternal heights.

Conclusion

IUGR infants grow faster but remain shorter and lighter than their normal counterparts—that is, they fail to fully catch up by 9 years of age.

Background

Smoking is a major risk factor for cot death. Many infants smoke passively as a result of parental smoking. This paper reports on infants exposed to a smoking environment and how they accumulate metabolites of cigarette smoke, such as cotinine, which may be physiologically harmful.

Aim

To assess cotinine levels in infants of smoking parents.

Method

Cotinine excretion in urine was assessed in 104 infants, of whom 71 had smoking parents and 33 had non‐smoking parents. All cotinine levels were measured at approximately 12 weeks of age. The subjects were selected from a database of infants in developmental physiological studies which assessed the impact of various factors on early postnatal development.

Results

On average babies with at least one parent who was a current cigarette smoker excreted 5.58 (95% CI 3.4 to 9.5) times as much cotinine in the urine as did the babies of non‐smoking parents. Maternal smoking was the largest contributing factor. Co‐sleeping (p = 0.037) and the minimum room temperature (p = 0.028) were significant contributory factors.

Conclusion

Infants from smoking households accumulate cotinine, a metabolite of nicotine, which may have a detrimental effect on the cardiorespiratory system.

Objective

To measure the zinc, copper, selenium and manganese blood levels in a cohort of 68 preterm infants, and to establish any associations with growth and/or dietary intake.

Design

Blood samples were collected at an infant's expected date of delivery (term) and 6 months later. Serum zinc, plasma copper and whole blood manganese were analysed by atomic absorption spectrometry, plasma and red cell selenium were determined by mass spectrometry. Growth and dietary intake determinations have been previously published.

Setting

Hampshire, England.

Results

Mean (SD) birth weight of the infants was 1.47 (0.434) kg and mean gestation was 31.4 (2.9) weeks. Mean blood levels at term and 6 months were: serum zinc 12.0 (2.6) µmol/l and 13.8 (2.5) µmol/l; plasma copper 10.1 (2.6) µmol/l and 19.2 (3.6) µmol/l; plasma selenium 0.49 (0.15) µmol/l and 0.72 (0.14) µmol/l; red blood cell selenium 1.68 (0.40) µmol/l and 1.33 (0.19) µmol/l; and blood manganese 320 (189) nmol/l and 211 (68) nmol/l, respectively. There were no significant associations between levels of zinc and copper and dietary intakes of those nutrients at either age (dietary intakes of selenium and manganese were not determined). Only copper levels at term were significantly associated (r = 0.31; p = 0.05) with a growth parameter (head circumference).

Conclusion

These results provide new information about trace element status in this vulnerable population.