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Clinical and electrophysiologic predictors of outcome in high-risk newborns: A 5-year prospective study
Seventh Congress of the International Child Neurology Association October 2-8, 1994
San Francisco, California
ABSTRACTS 1. PREDICTION OF SEVERE ADVERSE OUTCOME AFTER MODERATE OR SEVERE BIRTH ASPHYXIA Maja Steinlin, Paul G. Ekert, Susan Blaser, Hiroshi Otsubo, Margot J. Taylor, Hilary E. Whyte, and Max Perlman, Toronto, Canada
We wished to predict severe, adverse outcome in term infants with birth asphyxia as defined in an earlier study [1]. Perinatal data (i.e., perinatal risk factors, neurologic findings, other organ ischemia, therapies and laboratory findings, neuroimaging, and electrophysiology) were collected retrospectively for 1984-1991 (n = 109). We report the results of univariate analyses of the association between the more important findings. Predictors included: FHR = type II decelerations or sustained bradycardia, SR = spontaneous respiration onset > 10 min, AO = anuria, oliguria >48 hours, EOS = early-onset seizures within 6 hours; SP = persistent seizures over 48 hours; VEP ---- absent visual evoked potentials; EEG = severe abnormalities (i.e., electrocerebral silence, flat or burst suppression background). The primary outcome was death (n = 11) or severe quadriparesis and severe mental retardation (n = 30). Odds ratio (OR), confidence interval (CI), and P values are listed in Table 1. These variables strongly associated with severe adverse outcomes and will together with other recognized perinatal risk factors for severe brain damage be subjected to multivariate analyses. Reference: [1] Taylor MJ, Murphy WJ, Whyte HE. Prognostic reliability of SEPs and VEPs in asphyxiated term infants. Dev Med Child Neurol 1992;34:507-15. Table 1-1.
SR: EOS: VEP: FI-IR: AO: SP: EEG:
OR
CI
P Value
3.91 8.25 12.4 2.73 4.88 10.07 11.28
(1.3, 12.15) (3.25, 23.06) (3.8, 42.42) (1.30, 5.79) (1.48, 17.00) (3.44, 30.38) (3.37, 35.46)
<.002 <.0001 <.0001 <.006 <.006 <.0001 <.0001
2. CLINICAL AND ELECTROPHYSIOLOGIC PREDICTORS OF OUTCOME IN HIGH-RISK NEWBORNS: A 5-YEAR PROSPECTIVE STUDY Annette Majnemer, Bernard Rosenblatt, and Patricia Riley, Montreal, Canada Neonatal intensive care unit survivors are at risk for a range of sequelae that are often not evident until school age. Recent investigations indicate that evoked potentials are good predictors of early neuromotor outcome; however, their long-term predictive value is unknown. In this prospective study, healthy (n =
24) and high-risk newboms (n = 78) were evaluated in the newborn period with auditory brainstem evoked responses (ABRs) and somatosensory evoked responses (SERs), as well as the Einstein Neonatal Neurobehavioral Assessment Scale (ENNAS). Healthy and high-risk infants were evaluated in a blind fashion at 1, 3, and 5 years by a psychologist and pediatric neurologist. Of those healthy (all 24) and high-risk newborns (72 of 78) with neonatal ABR and/or SER, 62.5% were evaluated at 5 years using the Wechsler Preschool and Primary Scale of Intelligence, the Beery-Buktenica Developmental Test of VisualMotor Integration, the Griffiths Locomotor Subscale, and neurologic examination. Results revealed that the ENNAS and ABRs had good negative predictive value for cognitive (85.793.3%), locomotor (83.3%), and visual-motor (94.1-100%) performance. ABRs had good specificity, whereas the ENNAS was more sensitive. SERs were found to be an excellent prognostic tool, with high sensitivity (100%) and specificity (80-81.3%) for motor and cognitive domains. All infants with normal neonatal SERs had favorable outcomes, whereas those with absent potentials did poorly. Increased conduction time (N13-N19) or absent N19 potentials were associated with abnormalities on neurologic examination at 5 years in all patients. Early identification of perinatal brain injury is essential, so that effective remediation may begin without delay, maximizing the functional potential of these children.
3. MRI FOLLOW-UP OF HIGH-RISK PRETERM INFANTS Ingeborg Kr~igeloh-Mann, Peter Toft, Jytte Lunding, Jente Andresen, Ole Pryds, and Hans C. Lou, Tiibingen, Germany, and Copenhagen, Denmark
The most common major handicap in preterm children, bilateral spastic cerebral palsy (BSCP), was demonstrated in a series representative of the population to be present in 87% who had periventricular leukomalacia (PVL) [1]. To study the question of whether other minor or major handicaps, also typical for preterm children, are related to similar lesion patterns, a prospective study of high-risk preterm children (<32 weeks gestational age, ventilated) was undertaken. Twenty-one children followed at the Rigshospital of Copenhagen during the neonatal period were examined neurologically, psychologically, and by MRI at age 51/2-7 years of age. Ten had CP (9 BSCP, 1 hemiplegia). Of 11 neurologically normal children, 2 were mentally retarded, 4 had learning or attention-deficit problems, and 3 decreased visual acuity. All CP children had PVL patterns involving the pyramidal tracts. Six of the neurologically normal children also had mild PVL, localized mainly in the trigonal area (5 with cognitive, 3 with visual problems). Three children had enlarged occipital horns and 2 normal scans. In addition, asymmetric cerebellar atrophy affecting the hemispheres was determined in 4
PEDIATRIC NEUROLOGY Vol. 11 No. 2 81
San Francisco, California
ABSTRACTS 1. PREDICTION OF SEVERE ADVERSE OUTCOME AFTER MODERATE OR SEVERE BIRTH ASPHYXIA Maja Steinlin, Paul G. Ekert, Susan Blaser, Hiroshi Otsubo, Margot J. Taylor, Hilary E. Whyte, and Max Perlman, Toronto, Canada
We wished to predict severe, adverse outcome in term infants with birth asphyxia as defined in an earlier study [1]. Perinatal data (i.e., perinatal risk factors, neurologic findings, other organ ischemia, therapies and laboratory findings, neuroimaging, and electrophysiology) were collected retrospectively for 1984-1991 (n = 109). We report the results of univariate analyses of the association between the more important findings. Predictors included: FHR = type II decelerations or sustained bradycardia, SR = spontaneous respiration onset > 10 min, AO = anuria, oliguria >48 hours, EOS = early-onset seizures within 6 hours; SP = persistent seizures over 48 hours; VEP ---- absent visual evoked potentials; EEG = severe abnormalities (i.e., electrocerebral silence, flat or burst suppression background). The primary outcome was death (n = 11) or severe quadriparesis and severe mental retardation (n = 30). Odds ratio (OR), confidence interval (CI), and P values are listed in Table 1. These variables strongly associated with severe adverse outcomes and will together with other recognized perinatal risk factors for severe brain damage be subjected to multivariate analyses. Reference: [1] Taylor MJ, Murphy WJ, Whyte HE. Prognostic reliability of SEPs and VEPs in asphyxiated term infants. Dev Med Child Neurol 1992;34:507-15. Table 1-1.
SR: EOS: VEP: FI-IR: AO: SP: EEG:
OR
CI
P Value
3.91 8.25 12.4 2.73 4.88 10.07 11.28
(1.3, 12.15) (3.25, 23.06) (3.8, 42.42) (1.30, 5.79) (1.48, 17.00) (3.44, 30.38) (3.37, 35.46)
<.002 <.0001 <.0001 <.006 <.006 <.0001 <.0001
2. CLINICAL AND ELECTROPHYSIOLOGIC PREDICTORS OF OUTCOME IN HIGH-RISK NEWBORNS: A 5-YEAR PROSPECTIVE STUDY Annette Majnemer, Bernard Rosenblatt, and Patricia Riley, Montreal, Canada Neonatal intensive care unit survivors are at risk for a range of sequelae that are often not evident until school age. Recent investigations indicate that evoked potentials are good predictors of early neuromotor outcome; however, their long-term predictive value is unknown. In this prospective study, healthy (n =
24) and high-risk newboms (n = 78) were evaluated in the newborn period with auditory brainstem evoked responses (ABRs) and somatosensory evoked responses (SERs), as well as the Einstein Neonatal Neurobehavioral Assessment Scale (ENNAS). Healthy and high-risk infants were evaluated in a blind fashion at 1, 3, and 5 years by a psychologist and pediatric neurologist. Of those healthy (all 24) and high-risk newborns (72 of 78) with neonatal ABR and/or SER, 62.5% were evaluated at 5 years using the Wechsler Preschool and Primary Scale of Intelligence, the Beery-Buktenica Developmental Test of VisualMotor Integration, the Griffiths Locomotor Subscale, and neurologic examination. Results revealed that the ENNAS and ABRs had good negative predictive value for cognitive (85.793.3%), locomotor (83.3%), and visual-motor (94.1-100%) performance. ABRs had good specificity, whereas the ENNAS was more sensitive. SERs were found to be an excellent prognostic tool, with high sensitivity (100%) and specificity (80-81.3%) for motor and cognitive domains. All infants with normal neonatal SERs had favorable outcomes, whereas those with absent potentials did poorly. Increased conduction time (N13-N19) or absent N19 potentials were associated with abnormalities on neurologic examination at 5 years in all patients. Early identification of perinatal brain injury is essential, so that effective remediation may begin without delay, maximizing the functional potential of these children.
3. MRI FOLLOW-UP OF HIGH-RISK PRETERM INFANTS Ingeborg Kr~igeloh-Mann, Peter Toft, Jytte Lunding, Jente Andresen, Ole Pryds, and Hans C. Lou, Tiibingen, Germany, and Copenhagen, Denmark
The most common major handicap in preterm children, bilateral spastic cerebral palsy (BSCP), was demonstrated in a series representative of the population to be present in 87% who had periventricular leukomalacia (PVL) [1]. To study the question of whether other minor or major handicaps, also typical for preterm children, are related to similar lesion patterns, a prospective study of high-risk preterm children (<32 weeks gestational age, ventilated) was undertaken. Twenty-one children followed at the Rigshospital of Copenhagen during the neonatal period were examined neurologically, psychologically, and by MRI at age 51/2-7 years of age. Ten had CP (9 BSCP, 1 hemiplegia). Of 11 neurologically normal children, 2 were mentally retarded, 4 had learning or attention-deficit problems, and 3 decreased visual acuity. All CP children had PVL patterns involving the pyramidal tracts. Six of the neurologically normal children also had mild PVL, localized mainly in the trigonal area (5 with cognitive, 3 with visual problems). Three children had enlarged occipital horns and 2 normal scans. In addition, asymmetric cerebellar atrophy affecting the hemispheres was determined in 4
PEDIATRIC NEUROLOGY Vol. 11 No. 2 81