Perinatal Arterial Ischemic Stroke
Potential understanding may mean potential interventions and improved outcomes
In an article from Pediatrics in 2011, the International Pediatric Stroke Study (30 centers in 10 countries) reported on the conditions of 248 neonates with Perinatal Arterial Ischemic Stroke (PAIS). The authors reported that knowing what causes PAIS, and how, would require large-scale case-control studies. Only then might outcomes be improved. In some cases, PAIS may simply manifest as feeding problems, though these problems are not necessarily predictive of cerebral palsy or language disorders (J Child Neurol 2010; 25:867-872). Given that PAIS is a major contributor to perinatal brain injury, cerebral palsy and lifelong disability, all neonatologists should be interested in learning more about, and conceivably preventing, this condition (Pediatrics 2011;128:e1402-e1410). Now, two large case-control studies are available, one from the Netherlands and one from France.
Decision Making by Parents of Critically Ill Children
Brian Carter, MD, FAAP
This month, two articles have been selected that yield insights into how parents of critically ill children make decisions. While not solely specific to the world of neonatal-perinatal medicine, these two studies are revealing and remind us that parental decision-making is phenomenally complex and requires time, listening, a bidirectional exchange of a broad array of information, and sensitivity.
They conducted a narrative review of the current research literature and report on 55 papers from 52 distinct studies. They found that most studies were descriptive of the decision-making process and were qualitative. Actual decision outcomes were far less reported. And while parents’ preferences for their own degree of participation in pediatric decision making varied, most parents appear interested in sharing the decision with their health care professional – especially in the inpatient setting. Additionally, parents were reportedly influenced in their decision making by (a) changes in their child’s health status, (b) other community members (e.g., family or school community, others with disease-specific knowledge or experience), (c) prior knowledge of their child’s condition (e.g., longevity of illness or prior experience with another sibling), and (d) personal factors, such as emotions and faith. It is apparent that parents struggle to balance such influences. The authors encourage research to address decision outcomes, interventions to improve outcomes, and prospective trials to better understand how to support parents through difficult treatment decisions for their children.
Their NIH (NINR) sponsored study examined factors that 73 parents of 50 pediatric patients perceived as influencing their decision-making process. All patients in this study were receiving palliative care (1/3 of the children were in the NICU or PICU; roughly ¼ were < 1 year of age). The types of decisions that weighed heavily on these parents’ minds included where to deliver their baby and whether or not to have the baby admitted to an NICU, whether or not to get a G-tube placed, whether or not to get to get a 2nd opinion., whether or not to allow life extension devices, a blood transfusion, or provide an end-of-life directive, among others. Four themes were apparent: - those addressing their orientation and direction of care (including goals and hopes) - those which facilitated the discernment of what constitutes “what is good” for the child (including quality of life and suffering) - those addressing the importance of relationship, communication and support (the social and interactive nature of decision-making), and - those that addressed their own feelings and sense of personal accountability (their inward attention to their emotions and self-judgments). These influences obviously extend beyond what many caregivers consider the crux of decision-making: information exchange and some attention to risks and benefits. Accordingly, the authors suggest parental decision-support mechanisms should address these diverse influences.
Another perspective on neonatal caffeine therapy
Brian Carter, Vanderbilt University
A recently published report in JAMA on the 5-year outcomes from the CAP (Caffeine for Apnea of Prematurity) study is an excellent read for trainees and neonatologists alike. These investigators had previously reported their early outcomes at 18 months, including that caffeine improved the rate of survival without neurodevelopmental disability (OR adjusted for center, 0.77; 95% CI, 0.64-0.93) by reducing the risks of both cerebral palsy and cognitive delay. Recipients of caffeine were treated a median of 37 days. The primary outcome determinants at 5 years are a little different from the earlier trial
Neonatal HSV Infection: Diagnosis, Acute and Suppresive Treatment
Herpes simplex virus infection is associated with significant morbidity and mortality. It is not uncommon in the US, and incidence figures suggest that it is higher than in much of the developed world. Recent attention to surveillance may improve our understanding of this particular disease burden and help to develop educational, preventive, and treatment interventions to minimize the acute and long-term concerns associated with it. In a recent report from New York City, evidence is presented that reminds clinicians of obstetrical procedures that may negate the potential protective impact of operative cesarean section delivery (e.g., delivery >4 hours after rupture of membranes, artificial rupture of membranes, vacuum extraction, and use of indwelling instruments such as a fetal scalp electrode or intrauterine pressure catheters, or the use of forceps), and underscores the value of early recognition of the disease and implememtation of treatment. [Handel, et al. 2011].
The longterm concerns for newborns affected by systemic or central nervous sytem HSV infection are considerable, with 20 to 70% having neurological sequelae that include developmental delay, cognitive, communicative and motoric neurodisability, and seizures. ln a report from Kimberlin, et al. for the National Institute of Allergy and Infectious Diseases Collaborative Antiviral Study Group, the resuilts of a placebo controlled randomized trial that followed an initial 14-21 days of parenteral acyclovir [standard therapy] using 6 months of oral acyclovir versus placebo in those infants with CNS involvement demonstrated a statistically significant improvement in developmental assessment at age 1 year using the Mental Development Index (MDI) of the Bayley Scales of Infant & Toddler Development (3rd Ed.) Additionally, the 12-month Bayley MDI scores were incrementally higher as infants received acyclovir suppression for longer periods of time. While some attrition in the follow-up was noted, the end results indeed suggest benefit and the safety of this suppresive therapy is seemingly acceptable (some infants with neutropenia). Condidering that any CNS function lost due to the neurotropic nature and toxicity of HSV cannot be regained, the clinical benefit underscored in this trial is bound to impact future practice for all neonatal HSV infected patients.
1. Handel S, Klingler EJ, Washburn K, Blank S, Schillinger JA. Population-based surveillance for neonatal herpes in New York City, April 2006-September 2010. Sex Transm Dis. 2011 Aug;38(8):705-11. PMID: 21844721
2. Kimberlin DW, et al., for the National Institute of Allergy and Infectious Diseases Collaborative Antiviral Study Group. Oral Acyclovir Suppression and Neurodevelopment after Neonatal Herpes. N Engl J Med 2011;365:1284-92. »
Congenital Diaphragmatic Hernia
Congenital diaphragmatic hernia - and its attendant pulmonary hypoplasia and pulmonary hypertension - presents a formidable management challenge to neonatologists, surgeons, respiratory therapists and others NICU clinicians. The associated respiratory failure is known to be minimally responsive to surfactant (generally not used unless the patient is < 35 weeks' EGA) or inhaled nitric oxide (NO). But some evidence exists that eNOS is up-regulated in affected newborns [see Sood et al, below] and the plausibility of new strategies to enhance pulmonary parenchymal and vascular growth requires investigation. The 2nd and 3rd articles are offered as recent evidence for looking into potentially new approaches to improving outcomes for this condition.
3. de Buys Roessingh A, et al. Nitric oxide activity through quanylate cyclase and phosphodiesterase modulation is impaired in fetal lambs with congenital diaphragmatic hernia. J Pediatric Surgery 2011;46(8):1516-22. »
Resuscitation of the Preterm Infants
Retinopathy of Prematurity (ROP)
Retinopathy of prematurity (ROP) remains a major cause of blindness in the developed world where premature infants are cared for in modern intensive care units. As more and more extremely premature infants (<28 weeks’ EGA and <1,000g) survive, the incidence of severe ROP (generally Stages 3 to 4, or associated with plus-disease) is increasing. It remains important for all neonatologists to ensure appropriate screening for ROP in at-risk infants and provide timely referral for treatment in order to preserve the patient’s visual function and reduce later complications. This being said, ocular complications of prematurity apart from ROP also need to be considered, especially in the first ten years after NICU discharge (such as visual acuity concerns, strabismus, and visual motor function problems), especially in those infants <25 weeks’ EGA or those with significant IVH/PVL.
2. Reynolds JD: Bevacizumab for Retinopathy of Prematurity. N Engl J Med 2011; 364:677-678 (February 17, 2011). »
3. Chen J, Stahl A, Hellstrom A, Smith LE: Current update on retinopathy of prematurity: screening and treatment. Curr Opinion Pediatr 2011; 23 (2): 173-178. »
Periventricular Leukomalacia (PVL) and