To compare the effect of 2 doses of intravenous omeprazole on gastric pH, gastrointestinal bleeding, and adverse effects in critically ill children.
We undertook a prospective randomized clinical trial in critically ill children at risk of gastrointestinal bleeding. The effect of 2 intravenous omeprazole regimens (0.5 or 1 mg/kg every 12 hours) on the gastric pH and incidence of gastrointestinal hemorrhage was compared. The efficacy criteria were a gastric pH >4 and the absence of clinically significant gastrointestinal bleeding.
Forty patients, 20 in each treatment group, were studied. Overall, the gastric pH was greater than 4 for 57.8% of the time, with no difference between the doses (P = .66). The percentage of time with a gastric pH > 4 increased during the study (47.8% between 0 and 24 hours vs 76% between 24 and 48 hours, P = .001); the greater dose showed a greater increase in the percentage of time with a pH > 4: between hours 24 and 48 of the study, the gastric pH was greater than 4 for 84.5% of the time with the 1 mg/kg dose and for 65.5% of the time with the 0.5 mg/kg dose (P = .036). Plasma omeprazole levels were greater with 1 mg/kg dose, but no correlation was found between omeprazole plasma levels and gastric pH. No toxic adverse effects were detected, and there was no clinically significant bleeding.
Neither of the 2 omeprazole regimens achieved adequate alkalinization of the gastric pH during the first 24 hours. Between 24 and 48 hours, the 1 mg/kg dose maintained the gastric pH greater than 4 for a greater percentage of the time.
Differences in virologic response were compared in 32 HIV-infected children with a nelfinavir trough concentration either below (n=7) or above (n=25) 0.8 mg/L. Virologic response at week 48 was observed in 29% of children with subtherapeutic nelfinavir troughs versus 80% in children with therapeutic nelfinavir troughs (P=.02).
To compare the efficacy and safety of 5%, 3%, and 0.9% saline solution for treating acute bronchiolitis in the prehospital setting.
This was a double-blind trial including consecutive infants aged <18 months treated in an urban urgent care setting. A total of 165 patients were randomized to receive nebulized 5%, 3%, or 0.9% (normal) saline with epinephrine every 4 hours. The primary efficacy outcome was bronchiolitis severity score improvement at 48 hours (chi2 analysis). Scores and oxygen saturation immediately before and after each treatment were recorded to assess safety.
A total of 187 previously healthy infants (median age, 3.1 months) diagnosed with bronchiolitis were enrolled. Positivity for respiratory syncytial virus was similar in the 3 treatment groups (mean, 56%). At 48 hours, the mean severity score for the 5% saline group was 3.69+/-1.09, and that for the 0.9% saline group was 4.12+/-1.11 (P=.04; difference, 0.43, 95% confidence interval for the difference, 0.02-0.88). The mean severity score for the 3% saline group was intermediate at 4.00+/-1.22. Revisit rates after discharge were similar in the 3 treatment groups. No adverse reactions or other safety concerns were identified.
Nebulization with 5% hypertonic saline is safe, can be widely generalizable, and may be superior to current treatment for early outpatient treatment of bronchiolitis.
A nursery outbreak of gastroenteritis casued by Escherichia coli 0142/K86/H6 is described. Over a period of nine months, 59 epidemiologically linked cases of diarrhea occurred, including 21 intractable cases with four deaths. The epidemic strain, which was not agglutinated by commerical diagnostic antisera, was isolated from the hands of personnel in five instances directly incriminated hand carriage as the mode of spread. Acquisition of illness, which was especially high among low-birth-weight infants less than 17 days old, did not correlate with any treatment modality investigated and appeared to be related to a host factor. Noninvasive small intestinal colonization, production of enterotoxin, and multiple antibiotic resistance of the epidemic strain were demonstrated and helped to explain the intractability of clinical illness in many infants, despite intensive parenteral antibiotic therapy. Surveys of fecal coliforms on the hands of nursery personnel revealed no change in prevalence after introduction of a policy of "triple" handwashing with 3 percent hexachlorophene soap, but a significant decrease occurred during the use of disposable gloves. The frequent occurrence of E. coli 0142 in throat swabs of affected infants suggested that pharyngeal colonization may serve as an important diagnostic clue in E. coli diarrhea.
To assess measures of growth as prognostic indicators in response to zidovudine treatment in children with symptomatic human immunodeficiency virus infection.
We retrospectively assessed data from AIDS Clinical Trials Group Protocol 043, an open-label, phase II study of oral zidovudine therapy (180 mg/m2 per dose every 6 hours) in children with human immunodeficiency virus who have severe symptoms. Several variables were evaluated for their prognostic significance: CD4+ lymphocyte percentage; rates of weight gain and linear growth; entry weight, height, and weight-for-height z scores for age; race; gender; age; and route of transmission.
The overall survival rate as of April 1, 1992 (4 years after study initiation), was 44%, with a median survival of 37.9 months. The risk of death was greatest in children with CD4+ lymphocyte percentages < 20% (relative risk, 3.49), but was also increased in children who had a weight-for-age z score < -2 on entry to the study (relative risk, 1.53) and in those who failed to gain weight at the 25th percentile rate or greater during the first 6 months of therapy (relative risk, 2.03). These three factors, as well as race and gender, were found to be significant predictors in a multivariate, proportional-hazards model of survival. Entry height-for-age and height growth rates did not have predictive value for survival in univariate or multivariate analyses.
Weight-for-age and rate of weight gain are important, easily obtained, and inexpensive prognostic indicators in children with symptomatic human immunodeficiency virus treated with zidovudine. Both were less predictive of survival than the entry CD4+ lymphocyte percentage.
An outbreak of acute diarrheal disease developed in a household of nine members and affected four children and one adult. A nonlactose-fermenting coliform strain, Escherichia coli 075, was isolated from four patients. These patients either developed or had a high titer of antibodies in their serum against this microorganism, as demonstrated by the enterobacterial hemagglutination test. No parallel rises or similar levels in the titer of antibodies to heterologous enteric bacteria were found. The data suggest that the strain was etiologically related, in part at least, to the illness. It is suggested that study of the antibody response of patients may aid in the elucidation of the problem of the pathogenicity of suspect pathogens.
To describe the effect of zidovudine on human immunodeficiency virus type 1 (HIV-1) and on the course of disease in infants who became infected while they and their mothers received zidovudine preventive therapy or placebo in Pediatric AIDS Clinical Trials Group Protocol 076.
Observational substudy of a multicenter, randomized, double-blind, placebo-controlled trial.
We compared the progression of disease, timing of HIV-1 transmission, and the plasma HIV-1 RNA level in infected infants of mother-infant pairs who were randomly assigned to receive zidovudine (n = 14) or placebo (n = 43). The development of genotypic zidovudine resistance was assessed among infected infants in the zidovudine treatment group.
In this limited study, zidovudine therapy during pregnancy and labor and in the neonatal period for 6 weeks failed to have a major effect on rapid progression of disease, timing of transmission, and viral replication in HIV-infected infants. When the zidovudine treatment regimen failed to prevent maternal-infant transmission of HIV-1, resistance to zidovudine did not develop during study treatment.
Our study supports the safety of zidovudine use in pregnancy and in the newborn period but demonstrates the continued need for more potent antiretroviral treatment of the infected infant.
A study was made of 1,057 cases of poisoning in children treated as inpatients atMilwaukee Children's Hospital from 1962 through 1968. Data on date of occurrence, age and sex of the child, and type of agent involved were recorded and analyzed by standard statistical methods. Poisoning was due to ingestion of aspirin in 35 per cent of the children studied and to the ingestion of hydrocarbon distillates in 18 per cent. A statistically significant male dominance was found for ingestion of hydrocarbons; age-specific peaks were found for some categories. Trends as to the relative and absolute frequencies of each specific poison from one year to the next were noted; possible reasons for increasing or decreasing trends are discussed.
Because of published data suggesting the inadequacy of once-every-4-weeks intramuscular injections of benzathine penicillin G for secondary rheumatic fever prevention, serum penicillin levels were determined at 1, 3, 10, 21, and 28 days after administration of 1,200,000 units of this repository penicillin. A total of 193 samples were studied. Mean serum penicillin levels remained greater than or equal to 0.02 micrograms/ml for 21 days, but by 28 days only 44% of the serum samples had detectable levels of penicillin and only 36% had levels greater than or equal to 0.02 micrograms/ml. Patients weighing more than 45 kg had significantly lower serum penicillin levels than did those who weighed less. There were similar correlations with body surface area and with age. These data indicate that a significant percentage of patients receiving benzathine penicillin G prophylaxis for prevention of recurrent attacks of rheumatic fever are not protected during the fourth week. More frequent administration of benzathine penicillin G should be considered in instances of high risk of recurrence of rheumatic fever.
Elevated 1,25 dihydroxyvitamin D concentrations were found in five VLBW infants who developed rickets at two to three months postnatal age or term postconceptual age; 25 hydroxyvitamin D concentrations were low. Bone mineralization was found to be extremely low as measured by infant-adapted direct photon absorptiometry. After treatment with a formula supplemented with additional Ca and P, there was a rapid improvement in bone mineralization with a concomitant decrease of 1,25(OH)2D to normal adult values, whereas 250HD values increased and parathyroid hormone values decreased. In the VLBW infants studied, we suggest that rickets may be caused by Ca and P deficiency rather than by a deficiency of vitamin D metabolism.
Two children with congenital hypoparathyroidism and two children with pseudohypoparathyroidism were given maintenance doses of 15 to 45 ng/kg/day 1,25-dihydroxyvitamin D3 for a total of 255 months. The urinary calcium excretion showed an upward elevation after the first 2 years of treatment but was not significantly higher than that in 10 normal control subjects. The renal threshold for phosphate excretion stayed within the normal ranges compared with control values. Two hypercalcemic and two hypocalcemic episodes occurred during this period of treatment. Hypercalcemia was reversed within 1 week after withdrawal of 1,25-dihydroxyvitamin D3. Hypocalcemia was countered by increasing the dose of 1,25-dihydroxyvitamin D3. Renal functions were not adversely affected, as estimated by creatinine clearance and reciprocals of serum creatinine concentrations. The mean serum calcium concentration during 1,25-dihydroxyvitamin D3 treatment was significantly higher (P = 0.001) compared with that obtained during vitamin D2 treatment at a dose of 500 to 3000 IU/kg/day. These data provide additional support for the long-term use of 1,25-dihydroxyvitamin D3 in idiopathic hypoparathyroidism and pseudohypoparathyroidism.
The effects of 1,25(OH)2D3 in the prophylaxis of neonatal hypocalcemia were studied in 32 premature infants. Four groups of eight infants were matched individually for gestation and evidence of birth asphyxia, and given daily 1 μg of 1,25(OH)2D3, 0.05 μg/kg/day 1,25(OH)2D3, 400 IU vitamin D2, or placebo orally from 12 to 72 hours of age. Prestudy ionized calcium values were <3.5 mg/dl in all infants. By 48 hours, those given 1,25(OH)2D3, 1 μg/day, had significantly higher iCa values, 3.6±0.10 mg/dl (mean±SEM) vs 3.2±0.10 mg/dl at 12 hours (paired t, P<0.05). The concentration of total and ionized Ca was not different in the other three groups at 48 hours. Prestudy serum parathyroid hormone concentration was not different among the four groups, but by 48 hours, the group given 1 μg/ day 1,25(OH)2D3 had serum PTH values lower than pretreatment, 59±9 vs 137±58 μl-Eq/ml (Wilcoxon Rank, P<0.01) though not different than those in the other three groups. Prestudy 25-OH vitamin D values were correlated with gestational age (r=0.55, P<0.05). At 72 hours of age, an oral Ca tolerance test revealed a significant rise in serum Ca concentration at two and three hours in the infants given 1 μg/day of 1,25(OH)2D3, the average increase being 1.2 vs <0.5 mg/dl in the other three groups. 1,25(OH)2D3 may be useful for the prophylaxis of hypocalcemia.
Two infants with subcutaneous fat necrosis had hypercalcemia that normalized during glucocorticoid treatment. The combination of hypercalcemia, normal concentration of 25-hydroxyvitamin D, an elevated concentration of 1,25-dihydroxyvitamin D, a suppressed parathyroid hormone level, and low-normal bone turnover indicated abnormal 1,25-dihydroxyvitamin D production with increased intestinal absorption of calcium. Unregulated production of 1,25-dihydroxyvitamin D by the granulomatous cells of fat necrosis may cause hypercalcemia.
Osteodystrophy frequently accompanies severe childhood hepatobiliary disease. Proposed causes include malabsorption of vitamin D and calcium, and diminished 25-hydroxylation of vitamin D. Two children, ages 23 and 35 months, with radiographic and biochemical evidence of rickets with extrahepatic biliary atresia, were treated with 1,25-dihydroxyvitamin D3. The minimal effective therapeutic dose and efficacy of 1,25-(OH)2D3 in the treatment of rickets associated with severe childhood hepatic disease were determined. Oral 1,25-(OH)2D3 was ineffective at doses of 0.10 microgram/kg/day. Parenteral doses of 0.20 microgram/kg/day effectively produced radiographic, bone mineral (photon absorptiometric), and biochemical evidence of healing. The need for four times the physiologic dose of 1,25-(OH)2D3 by the parenteral route suggested enhanced catabolism of, or end-organ resistance to, 1,25-(OH)2D3 in our patients with severe cholestatic liver disease treated with phenobarbital.
Inappropriately elevated concentrations of 1,25(OH)2 vitamin D in serum appear to be responsible for excessive gastrointestinal absorption of dietary calcium in patients with absorptive hypercalciuria. We have examined serum 1,25(OH)2 vitamin D concentrations in another group of children with hypercalciuria in whom urinary calcium excretion was excessive after an overnight fast. Eleven children with idiopathic fasting hypercalciuria (IH) (urinary calcium excretion greater than 4 mg/kg/24 hr and fasting urinary calcium/urinary creatinine ratio greater than 0.21) and seven healthy children were observed while they were eating a diet containing 1 gm calcium per day. Fasting serum 1,25(OH)2 vitamin D concentrations were elevated in children with IH compared with control values (35.3 +/- 3.2 vs 21 +/- 2 pg/ml, P = 0.003), whereas fasting serum parathyroid hormone, 25-OH vitamin D, phosphorus, and ionized calcium concentrations were similar in the two groups. These data suggest that disordered 1,25(OH)2 vitamin D metabolism occurs in children with fasting IH. Absorptive and fasting IH may represent a spectrum of a single disorder characterized by excessive urinary calcium excretion and inappropriately elevated serum concentrations of 1,25(OH)2 vitamin D.
We evaluated the Greek screening program for glucose-6-phosphate dehydrogenase (G6PD) deficiency, which was incorporated into the existing national phenyketonuria (PKU) screening program to identify infants with G6PD deficiency and eliminate the induction of acute hemolytic crisis by informing the families about the extrinsic factors that G6PD-deficient patients should avoid. Between 1977 and 1989, 1,286,000 infants were screened. The fluorescent spot test was used on samples extracted from dried blood spots. Abnormal fluorescence due to G6PD deficiency (severe or partial) was found in 3.14% of the samples (1 in 22 males and 1 in 54 females). The sensitivity of the test for homozygosity and hemizygosity was 100%. In heterozygosity the test identifies only subjects who have considerably diminished enzyme activity. The test is inexpensive when added to the PKU screening program ($0.90 US per test). We believe that screening a population for G6PD deficiency is justified if the incidence of the deficiency in the population is high and the clinical manifestations serious. The fluorescent spot test is recommended because it is reliable, easy to perform, and inexpensive. The test must be performed within a fortnight from sampling, and the cards must not be exposed to high temperature or humidity.
Fat absorption was studied during the first 2 mo of life in 15 infants whose birth weights were less than 1,300 gm. Their capacity to absorb fat at 2 wk of age was midly impaired (79% of intake); it was significantly improved at 2 mo (88.4% of intake) and approached that of the adult. The degree of steatorrhea correlated inversely with intraluminal concentration of bile salts. In five infants who were given oral calcium supplements starting at 3 wk of age, fat excretion at 6–8 wk was significantly greater than in nonsupplemented infants.
α1,4 Glucosidase is absent from the liver, leukocytes, cultivated fibroblasts, and cultivated amniotic fluid cells from patients with Pompe's disease. In contrast, α1,4 glucosidase is present in the amniotic fluid and kidneys of these patients. The enzyme in amniotic fluid and kidney differs from the enzyme found in the other tissues in several properties, including pH optimum and inhibition by turanose. Amniotic fluid levels of α1,4 glucosidase cannot be used for the in utero diagnosis of Pompe's disease. The in utero diagnosis of this disorder requires the demonstration of the deficiency of α1,4 glucosidase in cultivated amniotic fluid cells.
The prenatal histories of 79 newborn infants who weighed 501 to 1,500 grams were compared by means of multiple regression and single variable analysis computer programs with groups of infants who weighed 1,501 to 2,500 grams and infants who weighed more than 2,500 grams. Abnormalities of pregnancy, including an abnormal reproductive history, rather than non-Caucasian race, clinic status, or chronic illness, were most characteristic of mothers who were delivered of infants of the lowest birth weights in contrast to the other two birth weight groups. Adverse socioeconomic factors, although accepted as being correlated with prematurity in general, were not correlated with the lowest birth weight group.
A two-year follow-up study of 73 low-birth-weight ( less than 1,501 gm) infants treated with positive pressure ventilation as neonates revealed the following: 24% incidence of lower respiratory tract infections during the first year; weight and height at two years averaging between tenth and twenty-fifth percentiles; major neurologic defects diagnosed in 14 boys (39%) and seven girls (18%) with one-year Bayley scores of less than 80. Major neurologic sequelae were closely associated with a neonatal history of seizures and intracranial hemorrhage and were more common in boys, survivors weighing more than 1,000 gm and following high-risk pregnancies.
Observation d'un enfant suivi de la naissance jusqu'a 2 ans, dont l'activite FDPase deficitaire a la naissance s'etait progressivement normalisee a l'âge de 5 mois et dont l'arrieration motrice et mentale persistante est probablement liee a l'hypoglycemie neonatale
To review the overall performance of a neonatal screening program for cystic fibrosis (CF) from 1981 to 1994, and to compare two strategies of case detection. PROGRAM DESIGN: Initially, immunoreactive trypsin (IRT) was measured in dried blood spots, and because of the low sensitivity of this test at days 3 to 5, a second sample was needed from babies with positive test results. Since 1993 a positive IRT assay result has been followed by direct gene analysis for the common CF mutation, delta F508, with the use of the same sample. Cases with false-negative results were actively sought throughout the period.
With IRT alone, 1,015,000 babies were tested. Of 389 babies with CF, 30 had a clinical diagnosis of CF made after a negative screening test result or an administrative error. Early diagnosis was achieved in 92%. With the IRT/DNA protocol, 59 of 62 infants had a positive screening test result (44 were homozygous for delta F508) among 189,000 babies tested. Three babies with CF had no copy of this mutation, but two were identified early because of meconium ileus. The false-positive rate was much greater for IRT alone than for the IRT/DNA test (0.69% vs 0.054%). All false-positive cases in the IRT/DNA protocol were, of necessity, CF carriers.
The percentage of babies with CF who had an early diagnosis was similar with the two protocols, but we concluded that the advantages of the IRT/DNA test for screening, particularly in the avoidance of the need for second IRT samples, outweighed the drawback of unwanted carrier detection.
The 1% silver nitrate, which has been used for preventing gonococcal conjunctivitis in the neonate, is not effective against Chlamydia trachomatis and may provoke eye irritation. It is not known whether the alternative topical agent, 1.25% povidone-iodine, can influence thyroid function. In this study, no influence of povidone-iodine on thyroid function was observed.
Weekly increments of length, weight, head circumference, and skinfold thickness in response to a series of dietary changes were measured in 108 healthy infants who weighed less than 1.3 kg at birth. The serial manipulations included prevention of late metabolic acidosis, increased caloric intake, and calcium, sodium, and phosphorus supplementation. The study comprised four phases; the infants were divided into ten groups according to dietary regimen. AGA and SGA infants were studied separately. Growth in length was primarily influenced by a change to a formula providing a higher caloric intake and a 60:40 whey protein/casein ratio. Correction of late metabolic acidosis, sodium, and phosphorus supplementation had minor additive effects on growth in length. Increased caloric intake also influenced growth of head circumference, but only in AGA infants. Only the sodium intake was shown to influence body weight increments significantly with the range of caloric intake used in the study (132 to 160 calories/kg/day).
Ten thousand children born consecutively in a university hospital were surveyed for the presence of major congenital malformations. About 2% (174) had a major congenital defect. Seventy-eight percent (135 of 174) of these malformations are associated with increased recurrence risk (greater than 1%), and 9% carry a high recurrence risk (greater than or equal to 10%). On the basis of the recurrence risk of 1% or higher and the feasibility of prenatal diagnosis, such a procedure should be considered in future pregnancies in 45% (79 of 174) of the mothers, especially inasmuch as 40% were primiparae younger than 36 years.
In this article we report the survival and morbidity rates for all live-born infants weighing 501 to 1000 gram at birth and born to residents of a defined geographic region from 1977 to 1980 (n = 255) compared with 1981 to 1984 (n = 266). During these periods, there were no changes in the proportion of infants delivered at the tertiary care center or community hospitals (171/84 vs 194/72); use of the tertiary care center increased only slightly, from 84% to 91%; and changes in neonatal management were mainly in improvements in diagnostic and monitoring techniques. When infants were grouped according to birth weights in 100 gm increments, survival improved significantly only for infants weighing between 501 and 600 gm at birth (2% vs 20% p less than 0.001). There were no differences in the overall survival rates to hospital discharge (46% vs 48%). The prevalence of neurosensory impairments was 24% in period 1 and 17% in period 2. There was a significant improvement in the proportion of infants considered to have disabilities by a functional classification assigned at 3 years corrected age (50% vs 27%, p less than 0.001), but only for infants weighing more than 800 gm at birth (49% vs 22%, p less than 0.001). Infants delivered at the community hospitals had a higher prevalence of neurosensory impairments compared with infants delivered at the tertiary care center (period 1, 35% vs 21%, not significant; period 2, 37% vs 14%, p less than 0.05). These data are encouraging; further efforts should be directed toward assessing which, if any, components of perinatal care are contributing to the improvement in morbidity rates.
To investigate whether recombinant erythropoietin (rhEPO) reduces the need for transfusion in extremely low birth weight (ELBW) infants (birth weight 500-999 g) and to determine the optimal time for treatment.
In a blinded multicenter trial, 219 ELBW infants were randomized on day 3 to one of 3 groups: early rhEPO group (rhEPO from the first week for 9 weeks, n = 74), late rhEPO group (rhEPO from the fourth week for 6 weeks, n = 74), or control group (no rhEPO, n = 71). All infants received enteral iron (3-9 mg/kg/day) from the first week. The rhEPO beta dose was 750 IU/kg/week. Success was defined as no transfusion and hematocrit levels never below 30%.
Success rate was 13% in the early rhEPO group, 11% in the late rhEPO group, and 4% in the control group (P =.026 for early rhEPO versus control group). Median transfusion volume was 0.4 versus 0.5 versus 0.7 mL/kg/day (P =.02) and median donor exposure was 1.0 versus 1.0 versus 2.0 (P =.05) in the early rhEPO group, the late rhEPO group, and the control group, respectively. Infection risk was not increased and weight gain was not delayed with rhEPO beta.
Early rhEPO beta treatment effectively reduces the need for transfusion in ELBW infants.
We tested the hypothesis that twice weekly prophylactic dosing of fluconazole prevents invasive candidiasis without promoting resistant Candida species in high-risk, preterm infants.
We compared our previous dosing schedule (Group A) to a less frequent dosing schedule of twice a week (Group B) of fluconazole prophylaxis for up to 6 weeks in a prospective, randomized, double-blind clinical trial in preterm infants weighing <1000 grams at birth and with an endotracheal tube and/or central vascular catheter over a 24-month period. Weekly surveillance cultures were obtained on study patients.
Candida colonization was documented in 5 (12%) of 41 Group A and in 4 (10%) of 40 Group B infants. Candida sepsis developed in two (5%) of Group A and one (3%) of Group B infants (risk difference, -0.02; 95% confidence interval, -0.14-0.10; P=.68). All fungal isolates remained sensitive to fluconazole, and no drug side effects were documented.
Twice weekly dosing of prophylactic fluconazole can decrease Candida colonization and invasive infection, cost, and patient exposure in high-risk, preterm infants weighing <1000 grams at birth. We speculate that lower and less frequent dosing may delay or prevent the emergence of antifungal resistance.
The intellectual and functional status of a regional cohort of children who weighed 501 to 1000 gm when born between 1980 and 1982 was evaluated at a mean age of 5 1/2 years by standard psychometric tests. Of 90 long-term survivors (survival rate 49%), 78 children (87%) had the full test battery, 5 children (6%) had other tests (4 were blind), and one child was untestable. Most of the mean scores were within 1 SD of the test norms; the lowest scores were in the McCarthy Motor scale and in the Beery Test of Visual-Motor Integration. Children without neurologic impairments and those with an IQ greater than or equal to 68 (n = 60) had higher overall scores but still performed poorly on the Motor subscale and the Beery test. Children who weighed less than 800 gm at birth (n = 28) were similar to those who weighed greater than 800 gm (n = 50), except in the Memory and Motor subscales, in which they performed significantly less well. At a functional level, determined by the Vineland Adaptive Behaviour Scales, two thirds of the children were performing in the adequate range and the remainder in the moderately low to low range. Of the 43 children with no neurosensory impairments and an IQ greater than or equal to 84, 49% were identified (by the Florida Kindergarten Screening Battery) to be at mild to high risk for future learning disabilities. The data from this unselected population provide an unbiased estimate of the prevalence of intellectual and functional problems in children who weighed less than or equal to 1000 gm at birth.
Of 55 consecutive long-term survivors of birth weight 500 to 999 g, complete psychologic and pediatric data were available for 54 children at 2 years corrected age and for 50 at age at least 5 1/2 years. At the latter age, 60% (30 of 50) were not impaired, 10% (five of 50) had severe sensorineural or intellectual impairments, 10% (five of 50) had mild to moderately impairment, and 20% (10 of 50) had minor neurobehavioural abnormalities. Sensorineural deafness in one child and bilateral blindness in one remained stable over time, but of six children with spastic cerebral palsy at 2 years, only three retained this diagnosis at 5 1/2 years. The mean Mental Developmental Index (MDI) on the Bayley Scales at 2 years was 91.1, significantly below the test mean; by 5 1/2 years the mean full scale of the Wechsler Preschool and Primary Scales of Intelligence (WPPSI) was 101.8. The MDI correlated highly with the full-scale WPPSI (r = 0.7), but for individual children it was not always an accurate predictor of 5-year ability. Between 2 and 5 1/2 years there was a substantial reordering within four categories of impairment: findings in 27 children were improved, four were judged to become more severely impaired over time, and 19 did not change. We conclude that our 2-year assessment often underrated the potential of the children as expressed at 5 1/2 years, and that 2 years is too early for reliable classification of children of birth weight 500 to 999 g.
To evaluate the effect of fluctuations in environment and body temperatures on preterm infants, we recorded these variables in very immature newborn infants (birth weight less than 1000 gm) cared for in double-walled incubators (Air-Shields model C-100 and Ohio model IC). Both incubators maintained environmental temperatures corresponding overall to the set point, despite incubator openings. Under skin temperature servocontrol, however, environmental temperature fluctuations were greater than 2 degrees C even in strictly controlled conditions. The pattern of incubator temperature fluctuations depended on the set point rather than on the type of incubator (conventionally heated or heated by warm air blown between the double walls). The long-term clinical significance of the incubator temperature variability remains to be determined; the choice between air and skin servocontrolling should depend in part on the need for environmental stability.