The anticipated delivery of an extremely low gestational age infant raises difficult questions for all involved, including whether to initiate resuscitation after delivery. Each institution caring for women at risk of delivering extremely preterm infants should provide comprehensive and consistent guidelines for antenatal counseling. Parents should be provided the most accurate prognosis possible on the basis of all the factors known to affect outcome for a particular case. Although it is not feasible to have specific criteria for when the initiation of resuscitation should or should not be offered, the following general guidelines are suggested. If the physicians involved believe there is no chance for survival, resuscitation is not indicated and should not be initiated. When a good outcome is considered very unlikely, the parents should be given the choice of whether resuscitation should be initiated, and clinicians should respect their preference. Finally, if a good outcome is considered reasonably likely, clinicians should initiate resuscitation and, together with the parents, continually reevaluate whether intensive care should be continued. Whenever resuscitation is considered an option, a qualified individual, preferably a neonatologist, should be involved and should be present in the delivery room to manage this complex situation. Comfort care should be provided for all infants for whom resuscitation is not initiated or is not successful.

Our prospective cohort study of extremely low gestational age newborns evaluated the association of neonatal head ultrasound abnormalities with cerebral palsy at age 2 years. Cranial ultrasounds in 1053 infants were read with respect to intraventricular hemorrhage, ventriculomegaly, and echolucency, by multiple sonologists. Standardized neurological examinations classified cerebral palsy, and functional impairment was assessed. Forty-four percent with ventriculomegaly and 52% with echolucency developed cerebral palsy. Compared with no ultrasound abnormalities, children with echolucency were 24 times more likely to have quadriparesis and 29 times more likely to have hemiparesis. Children with ventriculomegaly were 17 times more likely to have quadriparesis or hemiparesis. Forty-three percent of children with cerebral palsy had normal head ultrasound. Focal white matter damage (echolucency) and diffuse damage (late ventriculomegaly) are associated with a high probability of cerebral palsy, especially quadriparesis. Nearly half the cerebral palsy identified at 2 years is not preceded by a neonatal brain ultrasound abnormality. © 2009 Sage PublicationsAddress correspondence to: Karl C. K. Kuban, MD, SM Epi, 1 Boston Medical Center Place, Dowling 3 South, Boston, MA 02118; karl.kuban@bmc.org. Reprints: http://www.sagepub.com/journalsReprints.navThe authors have no conflicts of interest to disclose with regard to this article. Cranial ultrasound studies are used both to identify acute cerebral events in newborns and to assist with prognosis of motor and cognitive dysfunctions. For example, white matter damage, most often identified by a cranial ultrasound abnormality, is the single strongest predictor of cerebral palsy. [1][2][3][4][5][6][7][8][9][10][11] One limitation of many previous prognostic studies of neonatal ultrasound lesions is the reliance on a single sonologist to interpret scans. Because of the inherent variability in interpreting cranial sonograms, multiple readers may increase reliability. 12 Another limitation of previous prognostic studies is the lack of replicable operational definitions of cerebral palsy and its types. [1][2][3][4][5][6][7][8][9][10][11][13][14][15][16][17][18][19] In this article, we report how well cranial ultrasound scans obtained in the neonatal intensive care unit predicted cerebral palsy types and severity of motor dysfunction when children were 2 years old, corrected age. Our study of 1053 children born before the 28th postmenstrual week differs from previous studies in several ways. First, the protocol scans of these children were read by at least 2 independent sonologists for congruence about major abnormalities including intraventricular hemorrhage, moderate/severe ventriculomegaly, echogenic lesion, and echolucent lesion. Second, the sonologists' evaluation included specifically information about the location, extent, and laterality of these lesions. Third, the children were given a standardized neurological examination; the standardization of the examination res...

Background-Neurosonography can assist clinicians and can provide researchers with documentation of brain lesions. Unfortunately, we know little about the reliability of sonographically derived diagnoses.

Objectives To evaluate, in extremely low gestational age newborns (ELGANs), relationships between indicators of hypotension during the first 24 postnatal hours and developmental delay at 24 months of age. Methods The 945 infants in this prospective study were born at < 28 weeks, were assessed for 3 indicators of hypotension in the first 24 postnatal hours, and were evaluated with the Bayley Mental Development Index (MDI) and Psychomotor Development Index (PDI) at 24 months corrected age. Indicators of hypotension included: 1) mean arterial pressure (MAP) in the lowest quartile for gestational age; 2) treatment with a vasopressor; and 3) blood pressure lability, defined as the upper quartile for the difference between the lowest and highest MAP. Logistic regression was used to evaluate relationships between hypotension and developmental outcomes, adjusting for potential confounders. Results 26% of the cohort had an MDI < 70 and 32% had a PDI < 70. Low MDI and PDI were significantly associated with low gestational age, which in turn, was associated with receipt of vasopressor treatment. Blood pressure in the lowest quartile for gestational age was associated with vasopressor treatment and labile blood pressure. After adjusting for potential confounders, none of the indicators of hypotension was associated with MDI < 70 or PDI < 70. Conclusions In this large cohort of ELGANs, we found little evidence that early postnatal hypotension is associated with developmental delay at 24 months corrected gestational age.

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.