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Blood pressure (BP) is routinely measured in newborn infants. Published BP nomograms demonstrate a rise in BP following delivery in healthy infants at all gestational ages (GA) and evidence that BP values are higher with increasing birth weight and GA. However, the complex physiology that occurs in newborn infants and range of BP values observed at all GA make it difficult to identify "normal" BP for a specific infant at a specific time under specific conditions. As such, complete hemodynamic assessment should include the physical examination, perinatal history, other vital signs, and laboratory values in addition to BP values.

A suboptimal intrauterine environment is thought to increase the probability of deviation from the typical neurodevelopmental trajectory, potentially contributing to the etiology of learning disorders. Yet the cumulative influence of individual antenatal risk factors on emergent learning skills has not been sufficiently examined. We sought to determine whether antenatal complications, in aggregate, are a source of variability in preschoolers’ kindergarten readiness, and whether specific classes of antenatal risk play a prominent role. We recruited 160 preschoolers (85 girls; ages 3–4 years), born ≤336/7 weeks’ gestation, and reviewed their hospitalization records. Kindergarten readiness skills were assessed with standardized intellectual, oral-language, prewriting, and prenumeracy tasks. Cumulative antenatal risk was operationalized as the sum of complications identified out of nine common risks. These were also grouped into four classes in follow-up analyses: complications associated with intra-amniotic infection, placental insufficiency, endocrine dysfunction, and uteroplacental bleeding. Linear mixed model analyses, adjusting for sociodemographic and medical background characteristics (socioeconomic status, sex, gestational age, and sum of perinatal complications) revealed an inverse relationship between the sum of antenatal complications and performance in three domains: intelligence, language, and prenumeracy (p = 0.003, 0.002, 0.005, respectively). Each of the four classes of antenatal risk accounted for little variance, yet together they explained 10.5%, 9.8%, and 8.4% of the variance in the cognitive, literacy, and numeracy readiness domains, respectively. We conclude that an increase in the co-occurrence of antenatal complications is moderately linked to poorer kindergarten readiness skills even after statistical adjustment for perinatal risk. Electronic supplementary material The online version of this article (10.1007/s10802-019-00577-8) contains supplementary material, which is available to authorized users.

Objectives: To determine the recommended blood pressure (BP) measurement methods in neonates after systematically analyzing the international literature regarding proper BP cuff size and measurement location and method.\ud Study Design: A literature search was conducted in MEDLINE, PubMed, Embase, Cochrane Library and CINAHL from 1946 to 2017 on BP in neonates < 3 months of age (PROSPERO ID CRD42018092886). Study data was extracted and analyzed with separate analysis of Bland-Altman studies comparing measurement methods.\ud Results: Of 3587 non-duplicate publications identified, 34 were appropriate for inclusion in the analysis. Four studies evaluating BP cuff size support a recommendation for a cuff width to arm circumference ratio of ~0.5. Studies investigating measurement location identified the upper arm as the most accurate and least variable location for oscillometric BP measurement. Analysis of studies using Bland-Altman methods for comparison of intra-arterial to oscillometric BP measurement show that the two methods correlate best for mean arterial pressure (MAP) whereas systolic BP (SBP) by the oscillometric method tends to over-estimate intra-arterial SBP. Compared to intra-arterial methods, SBP, diastolic BP, and MAP by oscillometric methods are less accurate and precise, especially in neonates with a MAP

A female infant is born via spontaneous vaginal delivery at 40 weeks of gestation to a 34-year-old multigravida who has diet-controlled gestational diabetes. Meconium-stained amniotic fluid is noted with rupture of membranes 3 hours before delivery. The infant is vigorous after birth, with Apgar scores of 8 and 9 at 1 and 5 minutes, respectively. The neonate’s birthweight is 4,050 g (98th percentile). The initial physical examination findings are normal and she is allowed to room in with her mother. Vitamin K is administered within 1 hour of birth. Due to ineffective attempts at lactation, the neonate receives supplementation with term formula once during the first 24 hours. There is no documented void before 24 hours and a neonatology consultation is requested. During the physical examination in the newborn nursery, at 26 hours of age, she passes a large bloody stool with a significant amount of bright red blood. The infant appears well and nondistressed, with normal vital signs, good perfusion, and no respiratory distress. The abdomen is soft, nondistended, and nontender. No anal fissures are noted. Her examination findings are otherwise unremarkable. Review finds that she also had an episode of brownish emesis earlier in the day, which is attributed to swallowed maternal blood. The infant is transferred to the NICU. An Apt-Downey test on the stool could not be performed because the sample was contaminated with meconium and red blood cells could not be eluted. Laboratory results are as follows: hemoglobin, 14.1 g/dL (141 g/L); hematocrit, 40.8%; platelet count, 244×103/μL (244×109/L); C-reactive protein, 3.4 mg/dL (32.3 nmol/L); prothrombin time, 16.6 seconds; and partial thromboplastin time, 31.6 seconds. An abdominal radiograph demonstrates a …

Objective To investigate if magnetic resonance imaging (MRI) is an accurate predictor for death or moderate-severe disability at 18-22 months of age among infants with neonatal encephalopathy in a trial of cooling initiated at 6-24 hours. Study design Subgroup analysis of infants ≥36 weeks of gestation with moderate-severe neonatal encephalopathy randomized at 6-24 postnatal hours to hypothermia or usual care in a multicenter trial of late hypothermia. MRI scans were performed per each center's practice and interpreted by 2 central readers using the Eunice Kennedy Shriver National Institute of Child Health and Human Development injury score (6 levels, normal to hemispheric devastation). Neurodevelopmental outcomes were assessed at 18-22 months of age. Results Of 168 enrollees, 128 had an interpretable MRI and were seen in follow-up (n = 119) or died (n = 9). MRI findings were predominantly acute injury and did not differ by cooling treatment. At 18-22 months, death or severe disability occurred in 20.3%. No infant had moderate disability. Agreement between central readers was moderate (weighted kappa 0.56, 95% CI 0.45-0.67). The adjusted odds of death or severe disability increased 3.7-fold (95% CI 1.8-7.9) for each increment of injury score. The area under the curve for severe MRI patterns to predict death or severe disability was 0.77 and the positive and negative predictive values were 36% and 100%, respectively. Conclusions MRI injury scores were associated with neurodevelopmental outcome at 18-22 months among infants in the Late Hypothermia Trial. However, the results suggest caution when using qualitative interpretations of MRI images to provide prognostic information to families following perinatal hypoxia–ischemia. Trial registration Clinicaltrials.gov: NCT00614744 .

To determine if decreased cerebral oxygenation or altered cerebral autoregulation as measured by near-infrared spectroscopy (NIRS) in the first 96 postnatal hours is associated with an increased risk of death or severe neuroradiographic abnormalities in very preterm infants.The Early NIRS prospective, multicenter study enrolled very preterm infants with a birth weight of1250 g from 6 tertiary neonatal intensive care units. Mean arterial blood pressure and cerebral oxygen saturation (Csat) were continuously monitored using a neonatal sensor until 96 hours of age. Moving window correlations between Csat and mean arterial blood pressure determined time periods with altered cerebral autoregulation, and percentiles of correlation were compared between infants with and without the adverse outcome of mortality or severe neuroradiographic abnormalities by early cranial ultrasound.Of 103 subjects with mean gestational age of 26 weeks, 21 (20%) died or had severe neuroradiographic abnormalities. Infants with adverse outcomes had a lower mean Csat (67 ± 9%) compared with those without adverse outcomes (72 ± 7%; P = .02). A Csat of50% was identified as a cut-point for identifying infants with adverse outcome (area under the curve, 0.76). Infants with adverse outcomes were more likely to have significant positive or negative correlations between Csat and mean arterial blood pressure, indicating impaired cerebral autoregulation (P = .006).Early NIRS monitoring may detect periods of lower cerebral oxygenation and altered cerebral autoregulation, identifying preterm infants at risk for mortality or neuroradiographic injury. An improved understanding of the relationship between altered hemodynamics and cerebral oxygenation may inform future strategies to prevent brain injury.

Objectives: A limited body of research is available on the relationships between multiplicity of birth and neuropsychological functioning in preterm children who were conceived in the age of assisted reproductive technology and served by the modern neonatal intensive care unit. Our chief objective was to evaluate whether, after adjustment for sociodemographic factors and perinatal complications, twin birth accounted for a unique portion of developmental outcome variance in children born at-risk in the surfactant era. Methods: We compared the neuropsychological functioning of 77 twins and 144 singletons born preterm (Results: Multiple regression analyses, adjusting for sociodemographic and perinatal variables, revealed no differences on memory or motor indices between preterm twins and their singleton counterparts. In contrast, performance of language and visual processing tasks was significantly lower in twins despite reduced perinatal risk in comparison to singletons. Effect sizes ranged from .33 to .38 standard deviations for global language and visual processing ability indices, respectively. No significant group by sex interactions were observed, and comparison of first-, or second-born twins with singletons yielded medium effect sizes (Cohen’s d=.56 and .40, respectively). Conclusions: The modest twin disadvantage on language and visual processing tasks at preschool-age could not be readily attributable to socioeconomic or perinatal variables. The possibility of biological or social twinning-related phenomena as mechanisms underlying the observed performance gaps are discussed. (JINS, 2016, 22, 865–877)

Background The optimal upper and lower limits of blood pressure in preterm infants are not known. Exceeding these thresholds may contribute to intraventricular hemorrhage (IVH). Methods Preterm infants born ≤30 weeks GA were identified. Infants had continuous measurement of mean arterial blood pressure (MABP) for 7d and cranial ultrasound imaging. IVH was classified as severe IVH (grade 3/4), no severe IVH (no IVH; grade 1/2), or no IVH. Mean±SEM MABP values from hours 1–168 were calculated and sorted into bins 2 mmHg wide. The normalized proportion of each recording spent in each bin was then calculated. Candidate limits were identified by comparison of MABP distribution in those with severe IVH vs. those without severe IVH. Results 85 million measurements were made from 157 infants. Mean EGA was 25.2 weeks; mean BW was 749g; 65/157 female; inotrope use in 59/157; grade 3/4 IVH in 29/157. Infants with severe IVH spent significantly more time with extreme MABP measurements (46mmHg) compared to those without severe IVH (12% vs. 8% of recording, p=0.02). Conclusion Infants who developed severe IVH had substantially more unstable MABP and spent a significantly greater period of time with MABP outside of the optimal range.

Objective To examine changes in arterial blood pressure (ABP) after birth in extremely preterm infants. Study Design Prospective observational study of infants 230/7 – 266/7 weeks gestational age (GA). Antihypotensive therapy use and ABP measurements were recorded for the first 24 hours. Results A cohort of 367 infants had 18,709 ABP measurements recorded. ABP decreased for the first three hours, reached a nadir at 4 – 5 hours, then increased at an average rate of 0.2 mmHg / hour. The rise in ABP from hour 4 – 24 was similar for untreated infants (n=164) and infants given any antihypotensive therapy (n=203), a fluid bolus (n=135), or dopamine (n=92). GA specific trends were similar. ABP tended to be lower as GA decreased, but varied widely at each GA. Conclusion Arterial blood pressure increased spontaneously over the first 24 postnatal hours for extremely preterm infants. The rate of rise in ABP did not change with antihypotensive therapy.

For parents, the experience of having an infant in the NICU is often psychologically traumatic. No parent can be fully prepared for the extreme stress and range of emotions of caring for a critically ill newborn. As health care providers familiar with the NICU, we thought that we understood the impact of the NICU on parents. But we were not prepared to see the children in our own families as NICU patients. Here are some of the lessons our NICU experience has taught us. We offer these lessons in the hope of helping health professionals consider a balanced view of the NICU’s impact on families.

Sixty-four physician parents of infants cared for in the neonatal intensive care unit (NICU) were mailed a survey inquiring about privacy, emotional state, and communication. Fifty-seven (89%) physician parents responded. Forty-six (81%) infants were preterm. Responses were not associated with illness severity or hospital length of stay. Most respondents believed their infant received good care and achieved a good outcome, but suggestions to enhance communication were common, and their consideration may improve NICU care. Most physician parents believed their experience made them more empathetic and compassionate. Further investigation into the reasons for this may help to enhance future medical education.

Our aims were to identify the range of blood pressure values during the first postnatal week in infants born between 23 and 25 weeks postmenstrual age who were not considered in need of treatment for hypotension, and to describe the clinical course of these untreated infants compared with those who were treated for hypotension. We reviewed retrospectively the charts of 142 consecutive inborn infants over a 6-year period. For 86 infants who survived the first postnatal week without being treated for hypotension, the mean arterial pressure (MAP) increased 0.3 mm Hg/h during the first 24 hours, 0.1 mm Hg/h from the 25th to the 48th hour, and then stabilized for the remainder of the week. MAP values < or = 25 mm Hg were not uncommon and were not associated with apparent consequences. Thirty-five infants treated for hypotension differed significantly from untreated infants in several clinical variables present at birth, suggesting a different degree of fetal compromise. Treated infants were less likely to survive (43 versus 85%; P < 0.001) or survive without a major morbidity (29 versus 53%; P = 0.013) than untreated infants. It was not apparent from our data that the treatment of hypotension was helpful.

Objective To investigate the relationships between early blood pressure (BP) changes, receipt of antihypotensive therapy and 18–22 months’ corrected age (CA) outcomes for extremely preterm infants. Design Prospective observational study of infants 23 0/7 –26 6/7 weeks’ gestational age (GA). Hourly BP values and antihypotensive therapy exposure in the first 24 h were recorded. Four groups were defined: infants who did or did not receive antihypotensive therapy in whom BP did or did not rise at the expected rate (defined as an increase in the mean arterial BP of ≥5 mm Hg/day). Random-intercept logistic modelling controlling for centre clustering, GA and illness severity was used to investigate the relationship between BP, antihypotensive therapies and infant outcomes. Setting Sixteen academic centres of the Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network. Main outcome measures Death or neurodevelopmental impairment/developmental delay (NIDD) at 18–22 months’ CA. Results Of 367 infants, 203 (55%) received an antihypotensive therapy, 272 (74%) survived to discharge and 331 (90%) had a known outcome at 18–22 months’ CA. With logistic regression, there was an increased risk of death/NIDD with antihypotensive therapy versus no treatment (OR 1.836, 95% CI 1.092 to 3.086), but not NIDD alone (OR 1.53, 95% CI 0.708 to 3.307). Conclusions Independent of early BP changes, antihypotensive therapy exposure was associated with an increased risk of death/NIDD at 18–22 months’ CA when controlling for risk factors known to affect survival and neurodevelopment. Clinical trial registration number clinicaltrials.gov #NCT00874393.

We describe a case of cutaneous T-cell lymphoma occurring in a 21-year-old male with Wolf-Hirschhorn syndrome (WHS) due to a chromosome 4p16.3 deletion. This is the first documented case report of malignancy occurring in an adult with WHS. We also review the literature regarding patients with WHS and the joint occurrence of malignancy and discuss genetic changes involving chromosome 4 which may have contributed to the genesis of our patient's lymphoma.

OBJECTIVE: To investigate the relationships among blood pressure (BP) values, antihypotensive therapies, and in-hospital outcomes to identify a BP threshold below which antihypotensive therapies may be beneficial. METHODS: Prospective observational study of infants 230/7 to 266/7 weeks’ gestational age. Hourly BP values and antihypotensive therapy use in the first 24 hours were recorded. Low BP was investigated by using 15 definitions. Outcomes were examined by using regression analysis controlling for gestational age, the number of low BP values, and illness severity. RESULTS: Of 367 infants enrolled, 203 (55%) received at least 1 antihypotensive therapy. Treated infants were more likely to have low BP by any definition (P < .001), but for the 15 definitions of low BP investigated, therapy was not prescribed to 3% to 49% of infants with low BP and, paradoxically, was administered to 28% to 41% of infants without low BP. Treated infants were more likely than untreated infants to develop severe retinopathy of prematurity (15% vs 8%, P = .03) or severe intraventricular hemorrhage (22% vs 11%, P < .01) and less likely to survive (67% vs 78%, P = .02). However, with regression analysis, there were no significant differences between groups in survival or in-hospital morbidity rates. CONCLUSIONS: Factors other than BP contributed to the decision to use antihypotensive therapies. Infant outcomes were not improved with antihypotensive therapy for any of the 15 definitions of low BP investigated.

Background: The mortality rate for term infants varies by location and maternal demographics, but the relationship between these factors and the extremely preterm Infant Mortality Rate (IMR) may be different. Understanding the epidemiology of the extremely preterm IMR is important because infants born before 28 weeks gestation account for more than one-third of all infant deaths. Objectives: 1) Estimate the extremely preterm IMR for different states and locations (urban versus rural county) of the United States; 2) evaluate the impact of maternal race and education on this IMR and; 3) investigate the timing of death for extremely preterm infants who die in the first year. Methods: Data were analyzed from the National Center for Health Statistics to investigate the influence of birth location, maternal race, and maternal education on the IMR for infants born alive in the United States at 200/7-276/7 weeks gestation from 1995-2005. Results: The IMR was 392/1,000 live births for the 306,502 extremely preterm infants investigated. The extremely preterm IMR varied by maternal race and was highest for infants born to White mothers (397, 95% confidence interval (CI): 395, 399) and lowest for those born to Black/African American mothers (386, 95% CI: (383, 389)). Rural county birth was associated with a higher extremely preterm IMR than urban county birth (p=0.006). Maternal education had a bimodal relationship with the extremely preterm IMR such that the highest rates occurred with the least or greatest amount of education. With multi-variable analysis, birth in a rural county and maternal race negated the effects of maternal education on the extremely preterm IMR. Conclusion: The extremely preterm IMR varies widely based on demographics known at the time of delivery. This variability is distinct from that observed for more mature infants and may partially explain differences in IMR across neonatal intensive care units.

Objective To investigate the impact of in utero selective serotonin reuptake inhibitor (SSRI) exposure on neurodevelopment in a cohort of preterm infants. Study Design Retrospective case control study of preterm infants ≤36 6 / 7 weeks gestation with in utero SSRI exposure. Subjects were matched to controls by gestational age, year of birth, birth weight, gender, and age at neurodevelopmental assessment. Neurodevelopment was assessed with the Bayley Infant Neurodevelopmental Screener and the Bayley Scales of Infant Development. Results The 19 infants with in utero SSRI exposure were similar to controls in demographic data, birth weight, and in-hospital morbidity. The mean ± standard deviation (SD) Mental Developmental Index score for study infants at 36 months was 94 ± 15 versus 91 ± 10 for controls ( p = 0.46). The mean ± SD Psychomotor Developmental Index score was also similar between groups: 79 ± 21 for study infants versus 75 ± 20 for control infants ( p = 0.72). Other neurodevelopmental outcomes were comparable. Conclusion In this cohort of preterm infants, in utero SSRI exposure was not associated with adverse neurodevelopment above the baseline risk for this degree of prematurity. Larger studies are needed to obviate the risk of a type II error.

We describe an unusual case of an intra-abdominal teratoma with massive bleeding presenting as sudden cardiovascular collapse immediately after birth. The infant required massive volume and blood product transfusion, alongside emergent tumour resection, in order to obtain haemostasis and haemodynamic stabilisation. Haemorrhage of a sacrococcygeal teratoma is a known entity, but we are not aware of a previous report of massive intra-abdominal haemorrhage due to a teratoma, immediately after birth. This case emphasises the need to consider intra-abdominal pathology, including a teratoma, in the differential diagnosis of any newborn with early hypovolaemic shock and abdominal distention.

Retroperitoneal lymphatic malformations can cause significant displacement, pressure, or entrapment of adjacent organs raising suspicion of a malignant retroperitoneal tumor. They often mimic ascites but may rarely be a cause of ascites. Computed tomography (CT) imaging findings in an infant with a cystic retroperitoneal lymphatic malformation and massive chylous ascites are reported.

OBJECTIVES: To estimate trends in infant mortality rates and cesarean delivery rates for extremely preterm infants born in the United States. METHODS: This national population-based study used public data from the Centers for Disease Control and Prevention to investigate extremely preterm infants born alive between 22 0/7 and 27 6/7 weeks of gestational age from 1999 to 2005. RESULTS: There were 177,552 extremely preterm infant births (fewer than 1 % of all births) from 1999 to 2005. The number of annual extremely preterm births increased by 7% compared with a 4.5% increase for births at all gestations. During the study years, the extremely preterm infant mortality rate (percentage of infants who died in the first year) remained steady (range 33-34%; P=.22), whereas the cesarean delivery rate increased from 43% to 54% (P

Objective To compare neurodevelopment (ND) in 3 cohorts of extremely preterm infants: untreated with normal blood pressure (BP), untreated with low BP, and treated with low BP. Study design We conducted a retrospective study of infants 23 to 25 weeks gestation. Low BP was defined as ≥3 mean arterial pressures ≤25 mm Hg in the first 72 hours of life. Treatment included fluids, inotropes, and corticosteroids. Results We examined 67 infants with normal BP, 31 infants with untreated low BP, and 70 infants with treated low BP. A total of 75% survived to be discharged from the hospital, and 95% of survivors had ND assessment. Perinatal variables differed between treated infants with low BP and the other groups. Untreated infants with low BP had similar survival rates, but more cerebral palsy, deafness, or any ND impairment when compared with infants with normal BP. Treated infants with low BP had more mortality, worse ND, and less survival without ND impairment compared with infants who had normal BP. Results were unchanged after logistic regression adjusting for prenatal steroids, maternal education, race, sex, bronchopulmonary dysplasia, and postnatal dexamethasone exposure. Conclusions Infants with low BP—regardless of treatment—had worse ND than infants with normal BP. Early low BP may be independently associated with a poor outcome.

The outcome of babies born at the border of viability has always been, in part, a self-fulfilling prophecy as the high mortality rate for babies not maximally supported pre and postnatally has been used to justify a nonaggressive approach. Although undeniably beneficial to older premature babies, prenatal steroids (PS) have not been well studied in the smallest babies. Therefore we reviewed our experience with PS in 142 consecutive babies born with a gestational age (GA) of 23-25 wks from 1990-1995. The percentage of babies exposed to PS increased from 17% for 1990-1993 to 51% for 1994-1995(p

It is not clear why some premature babies who develop a GMH have an associated severe (S) IVH while others have only a GMH or minor (M) IVH. We reviewed the courses of 103 babies who developed a GMH within 7 postnatal days who were born with a gestational age (GA) of 23-32 wks from 1990-1995. Important differences between babies having only a GMH and those with an associated IVH included the following: Table There were no differences in gender distribution or the incidence of hyaline membrane disease requiring surfactant, prenatal steroids, or complications of prematurity. Clearly babies with an associated IVH were smaller, younger, and sicker. We then compared babies who had a GMH and M-IVH with those who had a GMH and S-IVH. Table