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Translational Pediatrics Feb 2020Cerebral palsy (CP) is a disorder characterized by abnormal tone, posture and movement and clinically classified based on the predominant motor syndrome-spastic... (Review)
Review
Cerebral palsy (CP) is a disorder characterized by abnormal tone, posture and movement and clinically classified based on the predominant motor syndrome-spastic hemiplegia, spastic diplegia, spastic quadriplegia, and extrapyramidal or dyskinetic. The incidence of CP is 2-3 per 1,000 live births. Prematurity and low birthweight are important risk factors for CP; however, multiple other factors have been associated with an increased risk for CP, including maternal infections, and multiple gestation. In most cases of CP the initial injury to the brain occurs during early fetal brain development; intracerebral hemorrhage and periventricular leukomalacia are the main pathologic findings found in preterm infants who develop CP. The diagnosis of CP is primarily based on clinical findings. Early diagnosis is possible based on a combination of clinical history, use of standardized neuromotor assessment and findings on magnetic resonance imaging (MRI); however, in most clinical settings CP is more reliably recognized by 2 years of age. MRI scan is indicated to delineate the extent of brain lesions and to identify congenital brain malformations. Genetic tests and tests for inborn errors of metabolism are indicated based on clinical findings to identify specific disorders. Because CP is associated with multiple associated and secondary medical conditions, its management requires a multidisciplinary team approach. Most children with CP grow up to be productive adults.
PubMed: 32206590
DOI: 10.21037/tp.2020.01.01 -
Clinics in Perinatology Sep 2022According to the World Health Organization (WHO), 15 million babies are born preterm each year. Preterm infants are those born at less than 37 weeks, while extremely... (Review)
Review
According to the World Health Organization (WHO), 15 million babies are born preterm each year. Preterm infants are those born at less than 37 weeks, while extremely and very preterm neonates include those born at 22 to less than 32 weeks gestational age. Infants that fail to make it to term are missing a key part in neurodevelopment, as weeks 24 to 40 are a critical period of brain development. Neonatal brain injury is a crucial predictor for mortality and morbidity in premature and low birth weight (<1500 g) infants. Although the complications associated with preterm birth continue to be the number one cause of death in children under 5, the survival rates are increasing (Volpe, 2019). Despite this, the incidence of comorbidities, such as learning disabilities and visual and hearing problems, is still high. The functional deficits seen in these infants can be contributed to the white matter abnormalities (WMA) that have been found in 50% to 80% of extremely and very preterm neonates. While numerous, the etiology of the neonatal brain injury is essential for determining the mortality and morbidities of the infant, as there is an increased risk for both intraventricular hemorrhage (IVH) and periventricular leukomalacia (PVL), which can be attributed to their lack of cerebrovascular autoregulation and hypoxic events. Neuroimaging plays a key role in detecting and assessing these neurologic injuries that preterm infants are at risk for. It is essential to diagnose these events early on to assess neurologic damage, minimize disease progression, and provide supportive care. Brain MRI and cranial ultrasound (CUS) are both extensively used neuroimaging techniques to assess WMA, and it has become ever more important to determine the best imaging techniques and modalities with the increasing survival rates and high incidence of comorbidities among these infants.
Topics: Brain Injuries; Child; Female; Humans; Infant; Infant, Low Birth Weight; Infant, Newborn; Infant, Premature; Infant, Premature, Diseases; Premature Birth
PubMed: 36113927
DOI: 10.1016/j.clp.2022.06.001 -
Journal of Child Neurology Feb 2022Periventricular leukomalacia (PVL) is a term reserved to describe white matter injury in the premature brain. In this review article, the authors highlight the common...
AIM
Periventricular leukomalacia (PVL) is a term reserved to describe white matter injury in the premature brain. In this review article, the authors highlight the common and rare pathologies mimicking the chronic stage of PVL and propose practical clinico-radiological criteria that would aid in diagnosis and management.
METHODS AND RESULTS
The authors first describe the typical brain MRI (magnetic resonance imaging) features of PVL. Based on their clinical presentation, pathologic entities and their neuroimaging findings were clustered into distinct categories. Three clinical subgroups were identified: healthy children, children with stable/nonprogressive neurological disorder, and those with progressive neurological disorder. The neuroradiological discriminators are described in each subgroup with relevant differential diagnoses. The mimics were broadly classified into normal variants, acquired, and inherited disorders.
CONCLUSIONS
The term "PVL" should be used appropriately as it reflects its pathomechanism. The phrase "white matter injury of prematurity" or "brain injury of prematurity" is more specific. Discrepancies in imaging and clinical presentation must be tread with caution and warrant further investigations to exclude other possibilities.
Topics: Brain; Cerebral Palsy; Female; Gestational Age; Humans; Infant, Newborn; Leukomalacia, Periventricular; Magnetic Resonance Imaging; Male; Pregnancy; Pregnancy Complications; Risk Factors
PubMed: 34937403
DOI: 10.1177/08830738211026052 -
Pediatric Research Mar 2020White matter injury (WMI) is the most frequent form of preterm brain injury. Cranial ultrasound (CUS) remains the preferred modality for initial and sequential... (Review)
Review
White matter injury (WMI) is the most frequent form of preterm brain injury. Cranial ultrasound (CUS) remains the preferred modality for initial and sequential neuroimaging in preterm infants, and is reliable for the diagnosis of cystic periventricular leukomalacia. Although magnetic resonance imaging is superior to CUS in detecting the diffuse and more subtle forms of WMI that prevail in very premature infants surviving nowadays, recent improvement in the quality of neonatal CUS imaging has broadened the spectrum of preterm white matter abnormalities that can be detected with this technique. We propose a structured CUS assessment of WMI of prematurity that seeks to account for both cystic and non-cystic changes, as well as signs of white matter loss and impaired brain growth and maturation, at or near term equivalent age. This novel assessment system aims to improve disease description in both routine clinical practice and clinical research. Whether this systematic assessment will improve prediction of outcome in preterm infants with WMI still needs to be evaluated in prospective studies.
Topics: Brain; Brain Injuries; Echoencephalography; Humans; Infant; Infant, Newborn; Infant, Premature; Infant, Premature, Diseases; Leukomalacia, Periventricular; Magnetic Resonance Imaging; Neonatology; Predictive Value of Tests; White Matter
PubMed: 32218534
DOI: 10.1038/s41390-020-0781-1 -
Pediatrics Jul 2021The National Institute of Child Health and Human Development Neonatal Research Network recently proposed new, severity-based diagnostic criteria for bronchopulmonary...
BACKGROUND AND OBJECTIVES
The National Institute of Child Health and Human Development Neonatal Research Network recently proposed new, severity-based diagnostic criteria for bronchopulmonary dysplasia (BPD). This study provides the first benchmark epidemiological data applying this definition.
METHODS
Retrospective cohort study of infants born from 22 to 29 weeks' gestation in 2018 at 715 US hospitals in the Vermont Oxford Network. Rates of BPD, major neonatal morbidities, and common respiratory therapies, stratified by BPD severity, were determined.
RESULTS
Among 24 896 infants, 2574 (10.3%) died before 36 weeks' postmenstrual age (PMA), 12 198 (49.0%) did not develop BPD, 9192 (36.9%) developed grade 1 or 2 BPD, and 932 (3.7%) developed grade 3 BPD. Rates of mortality before 36 weeks' PMA and grade 3 BPD decreased from 52.7% and 9.9%, respectively, among infants born at 22 weeks' gestation to 17.3% and 0.8% among infants born at 29 weeks' gestation. Grade 1 or 2 BPD peaked in incidence (51.8%) among infants born at 25 weeks' gestation. The frequency of severe intraventricular hemorrhage or cystic periventricular leukomalacia increased from 4.8% among survivors without BPD to 23.4% among survivors with grade 3 BPD. Similar ranges were observed for late onset sepsis (4.8%-31.4%), surgically treated necrotizing enterocolitis (1.4%-17.1%), severe retinopathy of prematurity (1.2%-23.0%), and home oxygen therapy (2.0%-67.5%).
CONCLUSIONS
More than one-half of very preterm infants born in the United States died before 36 weeks' PMA or developed BPD. Greater BPD severity was associated with more frequent development of major neonatal morbidities, in-hospital mortality, and use of supplemental respiratory support at discharge.
Topics: Bronchopulmonary Dysplasia; Cerebral Intraventricular Hemorrhage; Gestational Age; Humans; Incidence; Infant; Infant, Newborn; Infant, Premature; Leukomalacia, Periventricular; Retrospective Studies; Severity of Illness Index; Vermont
PubMed: 34078747
DOI: 10.1542/peds.2020-030007 -
Biomedicines Dec 2022We asked whether hyperoxia might induce hypomyelination of the corpus callosum, clinically described as periventricular leukomalacia (PVL) of the severely preterm...
We asked whether hyperoxia might induce hypomyelination of the corpus callosum, clinically described as periventricular leukomalacia (PVL) of the severely preterm infant. Mouse pups and their nursing dams were placed in 80% oxygen from P4-P8, then removed to room air until P11. Corpus callosal sections were probed myelin immunofluorescence, tested for myelin basic protein concentration by Western blot, and both glial fibrillary acidic protein levels and apoptosis quantified. Density of corpus callosal capillaries were measured after lectin staining and hypoxia measured by Hypoxyprobe. Numbers of oligodendrocytes were quantified by immunohistochemistry. We next used hypoxiamimesis as a surrogate to hypoxia by comparing cerebral hypoxia inducible factor (HIF) stabilization to hepatic HIF stabilization. Hyperoxia induced hypomyelination and a reduction of corpus callosal capillaries. Hyperoxia decreased numbers of oligodendrocytes with an increase in corpus callosal fibrosis and apoptosis. Cerebral hypoxiamimesis induced hypomyelination whereas hepatic hypoxiamimesis alone increased myelination, oligodendrocyte numbers, and corpus callosal capillary density. Hepatic HIF-1 dependence on myelination was confirmed using the cre/lox hepatic HIF-1 knockout. These findings suggest that hyperoxia can induce hypomyelination through vasoobliteration and subsequent ischemia, adding a potential oxygen induced mechanism to the diverse causes of periventricular leukomalacia of the severely preterm infant. Targeting hepatic HIF-1 alone led to increased myelination.
PubMed: 36672545
DOI: 10.3390/biomedicines11010037 -
Brain and Nerve = Shinkei Kenkyu No... Jun 2022Cerebral palsy (CP) is a relatively common neurological disease, and its prevalence at a transitional age is estimated to be approximately 0.2% in Japan. We should...
Cerebral palsy (CP) is a relatively common neurological disease, and its prevalence at a transitional age is estimated to be approximately 0.2% in Japan. We should understand the pathology of CP, which causes various dysfunctions other than motor disturbances, for delivering a comprehensive treatment. Rapid progress in perinatal medicine has altered the underlying brain lesions. Bilateral spastic CP associated with visual cognitive impairment due to periventricular leukomalacia has becomethe most prevalent instead of dyskinetic CP due to kernicterus. New types of brain lesions found in very premature infants will be more common among adult CP in the future. Cerebellar injury causes disturbances in cognition and communication, and bilirubin encephalopathy causes severe motor impairment with marked dystonia. The latter needs various medical treatments, including botulinum toxin and intrathecal baclofen. Elevated risk of lifestyle-related and psychological diseases should also be considered.
Topics: Adult; Cerebral Palsy; Cognitive Dysfunction; Female; Humans; Infant; Japan; Pregnancy
PubMed: 35676210
DOI: 10.11477/mf.1416202117 -
Archives of Disease in Childhood. Fetal... Jul 2020To investigate the effect of a nursing intervention bundle, applied during the first 72 hours of life, on the incidence of germinal matrix-intraventricular haemorrhage...
OBJECTIVE
To investigate the effect of a nursing intervention bundle, applied during the first 72 hours of life, on the incidence of germinal matrix-intraventricular haemorrhage (GMH-IVH) in very preterm infants.
DESIGN
Multicentre cohort study.
SETTING
Two Dutch tertiary neonatal intensive care units.
PATIENTS
The intervention group consisted of 281 neonates, whereas 280 infants served as historical controls (gestational age for both groups <30 weeks).
INTERVENTIONS
After a training period, the nursing intervention bundle was implemented and applied during the first 72 hours after birth. The bundle consisted of maintaining the head in the midline, tilting the head of the incubator and avoidance of flushing/rapid withdrawal of blood and sudden elevation of the legs.
MAIN OUTCOME MEASURES
The incidence of GMH-IVH occurring and/or increasing after the first ultrasound (but within 72 hours), cystic periventricular leukomalacia and/or in-hospital death was the primary composite outcome measure. Logistic regression analysis was used to explore differences between groups.
RESULTS
The nursing intervention bundle was associated with a lower risk of developing a GMH-IVH (any degree), cystic periventricular leukomalacia and/or mortality (adjusted OR 0.42, 95% CI 0.27 to 0.65). In the group receiving the bundle, also severe GMH-IVH, cystic periventricular leukomalacia and/or death were less often observed (adjusted OR 0.54, 95% CI 0.33 to 0.91).
CONCLUSIONS
The application of a bundle of nursing interventions is associated with reduced risk of developing a new/progressive (severe) GMH-IVH, cystic periventricular leukomalacia and/or mortality in very preterm infants when applied during the first 72 hours postnatally.
Topics: Cerebral Hemorrhage; Cerebral Ventricles; Female; Humans; Incidence; Infant, Newborn; Infant, Premature; Logistic Models; Male; Neonatal Nursing; Netherlands; Patient Positioning
PubMed: 31732682
DOI: 10.1136/archdischild-2018-316692 -
JAMA Network Open Aug 2021The Chinese Neonatal Network was established in 2018 and maintains a standardized national clinical database of very preterm or very low-birth-weight infants in tertiary...
IMPORTANCE
The Chinese Neonatal Network was established in 2018 and maintains a standardized national clinical database of very preterm or very low-birth-weight infants in tertiary neonatal intensive care units (NICUs) throughout China. National-level data on outcomes and care practices of very preterm infants (VPIs) in China are lacking.
OBJECTIVE
To assess the care practices in NICUs and outcomes among VPIs in China.
DESIGN, SETTING, AND PARTICIPANTS
A cohort study was conducted comprising 57 tertiary hospitals from 25 provinces throughout China. All infants with gestational age (GA) less than 32 weeks who were admitted to the 57 NICUs between January 1 and December 31, 2019, were included.
MAIN OUTCOMES AND MEASURES
Care practices, morbidities, and survival were the primary outcomes of the study. Major morbidities included bronchopulmonary dysplasia, severe intraventricular hemorrhage (grade ≥3) and/or periventricular leukomalacia, necrotizing enterocolitis (stage ≥2), sepsis, and severe retinopathy of prematurity (stage ≥3).
RESULTS
A total of 9552 VPIs were included, with mean (SD) GA of 29.5 (1.7) weeks and mean (SD) birth weight of 1321 (321) g; 5404 infants (56.6%) were male. Antenatal corticosteroids were used in 75.6% (6505 of 8601) of VPIs, and 54.8% (5211 of 9503)were born through cesarean delivery. In the delivery room, 12.1% of VPIs received continuous positive airway pressure and 26.7% (2378 or 8923) were intubated. Surfactant was prescribed for 52.7% of the infants, and postnatal dexamethasone was prescribed to 9.5% (636 of 6675) of the infants. A total of 85.5% (8171) of the infants received complete care, and 14.5% (1381) were discharged against medical advice. The incidences of the major morbidities were bronchopulmonary dysplasia, 29.2% (2379 of 8148); severe intraventricular hemorrhage and/or periventricular leukomalacia, 10.4% (745 of 7189); necrotizing enterocolitis, 4.9% (403 of 8171 ); sepsis, 9.4% (764 of 8171); and severe retinopathy of prematurity, 4.3% (296 of 6851) among infants who received complete care. Among VPIs with complete care, 95.4% (7792 of 8171) survived: 65.6% (155 of 236) at 25 weeks' or less GA, 89.0% (880 of 988) at 26 to 27 weeks' GA, 94.9% (2635 of 2755)at 28 to 29 weeks' GA, and 98.3% (4122 of 4192) at 30 to 31 weeks' GA. Only 57.2% (4677 of 8171) of infants survived without major morbidity: 10.5% (25 of 236) at 25 weeks' or less GA, 26.8% (48 of 179) at 26 to 27 weeks' GA, 51.1% (1409 of 2755) at 28 to 29 weeks' GA, and 69.3% (2904 of 4192) at 30 to 31 weeks' GA. Among all infants admitted, the survival rate was 87.6% (8370 of 9552)and survival without major morbidities was 51.8% (4947 of 9552).
CONCLUSIONS AND RELEVANCE
The findings of this study suggest that survival and survival without major morbidity of VPIs in Chinese NICUs have improved but remain lower than in high-income countries. Comprehensive and targeted quality improvement efforts are needed to provide complete care for all VPIs, optimize obstetrical and neonatal care practices, and improve outcomes.
Topics: Adult; Birth Weight; China; Critical Care Outcomes; Delivery, Obstetric; Female; Gestational Age; Hospitalization; Humans; Infant; Infant Mortality; Infant, Extremely Premature; Infant, Newborn; Infant, Premature, Diseases; Intensive Care Units, Neonatal; Intensive Care, Neonatal; Male; Morbidity; Pregnancy; Survival Rate
PubMed: 34338792
DOI: 10.1001/jamanetworkopen.2021.18904 -
Cureus Jul 2021Premature birth is the most common cause for a stay in the neonatal intensive care unit (NICU) among neonates. Premature birth leads to prematurity, which is associated...
Premature birth is the most common cause for a stay in the neonatal intensive care unit (NICU) among neonates. Premature birth leads to prematurity, which is associated with complications such as respiratory distress syndrome (RDS), hyperbilirubinemia, gastroesophageal reflux (GERD), intraventricular hemorrhage (periventricular leukomalacia), retinopathy of prematurity (ROP), and so on. These secondary complications are of great concern and need to be handled with care to prevent the further deterioration of the quality of life of the baby as he grows. So, the early physiotherapeutic interventional approach comes into light and plays an important role in neonatal care.This case study demonstrates an infant boy of seven months chronological age, who had a preterm birth history with a poor APGAR (Appearance, Pulse, Grimace, Activity, and Respiration) score and NICU stay during the first three months of life. He approached the physiotherapy outpatient department with a complaint of delayed motor milestones like an absence of head holding, rolling, opening of hand, as well as delayed social-emotional development, Ryles tube (RT) in situ, with frequent episodes of GERD, neck rotated to the left side, high irritability, tactile defensiveness of both hands, and difficulty in regulating his sensory systems. Outcome measures used were gross motor function measure (GMFM), sensory profile, and rotating chair test. Early interventional physiotherapy was given including neurodevelopmental techniques (NDT), oromotor stimulation, sensory integration, passive stretching, and myofascial release for six days per week with each session of 45 minutes. The results demonstrated the achievement of motor milestones till sitting independently, reduced episodes of GERD, discontinued RT in situ, improved mobility of neck on both sides, reduced irritability, and started reaching, grasping along with bimanual tasks.
PubMed: 34434678
DOI: 10.7759/cureus.16581