Showing posts with label preterm. Show all posts
Showing posts with label preterm. Show all posts

Friday, October 16, 2015

Familiar with Early-Onset Neutropenia in a Small for Gestational Age Infant? After Reading a New Study You Will Be!

By: Lewis First, MD, MS; Editor-in-Chief      


        Small for gestational age (SGA) infants are known to have early neutropenia when compared to normal size infants at a gestational age—but just what do we know about this neutropenia?  How common is it? How long does it last?  What might be causing it and what makes it better?  
       These questions and more are answered in an informative study by Christensen et al. (doi: 10.1542/peds.2015-1638) being released this month in our journal who looked at ten years of neutropenia in the first week of life in more than 200 SGA infants out of 3600 studied compared to less than 50 out of 3650 non-SGA infants.  The authors looked at a variety of factors associated or not-associated with this neutropenia ranging from necrotizing enterocolitis to thrombocytopenia and give us a much clearer picture of what the “neutropenia of SGA” is all about.  
        If you want to know more about a common finding in your SGA newborns and what to follow and worry about (or not) in this neutropenic population, then reading this study should be an easy “cell.”

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Friday, August 28, 2015

ADHD Diagnosis – What Risk is defined at birth?


By: Lydia Furman, MD,  Assistant Editor 
 
     How do prematurity and fetal growth impact risk of ADHD? Comprehensive epidemiological studies from countries such as Finland that have universal health care, national tracking registries and relatively homogeneous populations can provide unique insights into challenging questions like this one. Dr. Sucksdorff et al. (doi: 10.1542/peds.2015-1043) have conducted a careful and thoughtful study whose conclusions have both pragmatic practice implications, as well as potential to stimulate new research.
      The authors were able to use national registries to identify all 900,603 live singleton births between 1991 and 2001, and then to further select the study subpopulations of (a) all 10,321 children who were diagnosed with ADHD and (b) 38,355 matched healthy controls. Very few had missing information or exclusionary diagnoses, and the authors are able to cite prior work showing that 88% of children with an ADHD Registry diagnosis who were subsequently examined did meet the DSM-IV diagnostic criteria for ADHD. The exposures of interest were (1) gestational age by week, and (2) sex-specific fetal growth for gestational age by standard deviation category (please read the paper for relevant details); obviously the outcome of interest was the diagnosis of ADHD. The authors were able to include 9 key confounding variables in the analysis, for example maternal smoking and parental psychiatric diagnoses, with sufficient detail and documentation to provide meaningful information.
      The results of the logistic regression analyses are convincing. Readers familiar with multiple studies examining risk for ADHD will likely not be surprised by the results, but the magnitude of the association of gestational age with ADHD diagnosis is highly persuasive. Are late preterm, “early term” and even younger term infants impacted? The information is presented clearly in both the text and tables, and I hope you will enjoy the read. Previous work has suggested that small for gestational age status increases risk for ADHD, but Dr. Sucksdorff and colleagues are able to show a beautifully “fine-grained” view of the impact of being either larger or smaller for gestational age on risk for ADHD diagnosis. In both analyses (gestational age and weight for gestational age) there are interesting surprises, as well as implications for how we classify gestational maturity and appropriateness of fetal growth for gestational age. And the article may influence practicing pediatricians to think differently about risk for ADHD diagnosis in individual children.
      As the authors note, given the limited socioeconomic differences and disparities in perinatal health in Finland, it is unlikely that these results are hiding uncontrolled social factors. So although it can be difficult to generalize results from one country to another, in this case a study setting that essentially controls for the myriad of social and health disparities in the US provides a unique opportunity for researchers to think more clearly about the etiology of ADHD. These authors found a very minor impact of familial factors after adjustment for confounders. They point out that the processes underlying fetal neurodevelopment, including “synaptogenesis, brain folding and myelination,” along with factors related to the multiple possible mechanisms of preterm labor including inflammation, infection and ischemia, may play an etiologic role in susceptibility to ADHD, i.e. to the behaviors of inattention, hyperactivity and impulsiveness. And taking this one step further, since susceptibility or risk for ADHD is not ADHD diagnosis, what postnatal environmental factors might “tip the ship” and lead to or be associated with diagnosis? We will need to await another careful and thoughtful study to answer this question… 

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Monday, August 10, 2015

Tracking Cognitive Function of Very Preterm and Very Low Birth Weight Infants into Adulthood

By: Lewis First, MD, MS; Editor-in-Chief       

The ability to follow a cohort of high-risk infants from birth into adulthood is becoming more and more commonplace nowadays. What we are learning about the life trajectories of preterm or low birth weight infants from these cohorts is fascinating, and this important new knowledge may help us to do more to improve long-term quality of life.  
Take for example the study by Breeman et al. (doi: 10.1542/peds.2015-0608) that we are publishing this week. The authors look at how cognitive function in very preterm (VP) and very low birth weight (VLBW) infants progresses over time compared to term infants.  The authors followed more than 250 VP/VLBW babies in a cohort over their first 25 years of life assessing development and IQ at multiple points over that period of time.  The results show that cognitive function is generally stable after 20 months for the VP/VLBW children and predictive of adult IQ whereas the cognitive function of term infants is not predictive of adult IQ until at least 6 years of age.  
The implications of this study suggest that we should do an even better job of assessing our VP/VLBW patients in  infancy and early toddlerhood so that developmental support services, if needed, can be implemented as early as possible with the hope of improving cognitive function.  As to why the differences between VP/VLBW cognitive stability and that of term infants, you will need to read this study and see how the authors develop their interpretation of the data—and there is lots more to learn from this important study.  It provides a remarkable look at the longitudinal follow-up of this unique, yet more and more common cohort of at-risk preterm and low birth weight patients.


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Tuesday, July 7, 2015

Understanding Morbidity and Mortality Concerns When Multiple Gestations Are Born Extremely Preterm

By: Lewis First, MD, MS; Editor-in-Chief 
 
     We are certainly aware of a myriad of potential complications that can occur to an extremely preterm infant and are grateful that our neonatology colleagues are there to help as needed.  But what if a mother in your practice gives birth to twins or triplets at an extremely preterm gestational age?  What advice do you give that family when they ask if this makes things better or worse for each individual twin or triplet infant?   
     Yeo et al. (doi: 10.1542/peds.2015-0479) share with us the results of a retrospective study of more than 15,000 infants born at or less than 27 weeks gestation from 1995-2009 into the Australian and New Zealand Neonatal Network in which singletons are compared to multiple gestation births in this preterm cohort.  There is a lot of data worth paying attention to in this study, with good news and bad news for multiple gestation infants compared to singletons born extremely preterm.  The bad news is that not unexpectedly, the odds of mortality in infancy are greater for multiples than for singletons across the 15 years studied.   
     The good news is that thanks to ongoing advances in neonatal care and technology, the odds of a poor outcome over the most recent 5 years studied is no different for multiple compared to single extremely preterm births.  If you are asked to care for a family expecting twins or triplets, and want to help them better understand what the future might hold if the babies are born earlier than expected, then labor a bit over this interesting study and deliver what you have learned in a way that hopefully will reassure expectant parents of multiple gestations as much as possible.

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