John M. Lorenz

Elevated urinary neutrophil gelatinase-associated lipocalin (uNGAL) predicts acute kidney injury (AKI) in children following cardiopulmonary bypass (CPB) during cardiac surgery, but little is known about uNGAL’s predictive ability in neonates in this setting. We sought to determine the relationship between AKI and post-CPB uNGAL in neonates in the first 72 post-operative hours. Methods: Urine samples for uNGAL analysis were collected at preoperative baseline and serially post-operatively from 76 neonates undergoing CPB. Mixed-effects regression models and logistic models assessed associations between uNGAL and AKI (controlling for sex, gestational age, CPB time, surgical complexity, and age at surgery). Receiver-operator curves were applied to define optimal uNGAL cut-off values for AKI diagnosis. Results: Between 0 and 4 h post-operatively, uNGAL values did not differ between neonates with and without AKI. After 4 h until 16 h post-operatively, significant time-wise separation occurred between uNGAL values of neonates with AKI and those without AKI. Odds ratios at each time point significantly exceeded unity, peaking at 10 h post-operatively (3.48 (1.58, 8.71)). Between 4 and 16 h post-operatively, uNGAL discriminated AKI from no-AKI, with a sensitivity of 0.63 (0.49, 0.75) and a specificity of 0.68 (0.62, 0.74) at a cut-off value of 100 ng/mL. Conclusion: After 4 h until 16 h post-operatively, elevated uNGAL is associated with AKI in neonates receiving CPB during cardiac surgery; however, this relationship is more complex than in older children.

Survival rates among live births in North American tertiary perinatal centers since 1990 were 28% at 23 weeks, 52% at 24, 70% at 25 and 83% at 26 weeks. However, there is wide variation among centers. Survival rates in 2010 among tertiary centers in the United States participating in the Vermont-Oxford Network were 34% at 23 weeks, 61% at 24, 79% at 25, and 87% at 26. All reports of neurodevelopmental outcome of extremely preterm infants in the English literature were reviewed. This literature is very heterogeneous and prevalence highly variable. Major limitations are astonishing variation in criteria for major disability and that, even with the same disability criteria, children with major disabilities are functionally very heterogeneous. Mean prevalence of disability in the literature is 36%, but ranges from 10-61%. This literature could be improved if survivors were followed until early school age, there were more uniform reporting by week of gestation, and outcomes of term control groups were included.

Objective: To determine in low birth weight infants the relations of being small for gestational age at birth, microcephalic at birth, low weight for age at 2 years, and microcephalic at 2 years to full scale intelligence quotient (FSIQ) at the age of 16 years. Methods: A prospective observational study of 422 of 837 eligible nondisabled low birth weight (β = −0.14, p = .02) and microcephalic at 2 years (β = −0.18, p < .001), but not low weight for age at 2 years or microcephaly at birth, had significant independent effects on 16-year FSIQ. After adjusting for pre-, peri-, and postnatal risk factors for poor cognitive performance, the independent effects of being small for gestational age (β = −0.13, p = .004) and microcephalic at 2 years (β = −0.13, p = .01) persisted. In this analysis, birth social risk had the largest significant independent effect on 16-year FSIQ (β = −0.28, p < .001). Conclusions: Being small for gestational age at birth, but not low weight for age at 2 years, and microcephaly at 2 years, but not at birth, were independently related to FSIQ of nondisabled low birth weight adolescents, both with and without control for pre-, peri-, and postnatal risk factors.

Summarize the literature relevant to ethical issues surrounding decisions to provide intensive care to extremely premature newborns. A Texas Supreme Court decision and a position paper are noteworthy for health professionals participating in management decisions with families at risk for extremely preterm delivery. In Miller v HCA, the Millers sued the Hospital Corporation of America for resuscitating their approximately 23-week gestation daughter against their wishes. The baby survived with severe neurodevelopmental disabilities. They were awarded $59.9 million in a jury trial. However, the judgment was reversed by the court of appeals, which ruled that parents have no right to withhold urgently needed life-sustaining medical treatment from children with non-terminal impairments, deformities, or disabilities, regardless of their severity. The Supreme Court of Texas upheld that ruling, but reasoned that parents have no right to refuse resuscitation of extremely premature infants prior to birth because they cannot be fully evaluated until birth; therefore, decisions before birth could not be fully informed. Robertson (Hasting Center Report 2004) supports precluding parental refusal of resuscitation before birth. He argues that parents have a right to withhold or withdraw medical treatment from a non-terminally ill child, but only if the child will lack capacity for symbolic interaction. Such severe limitation of quality of life concerns in decision making for extremely premature newborns is inconsistent with current published guidelines, the positions of noted bioethicists, and the practice of many neonatologists. Further, the additional information attained by initiating intensive care in the most premature infants does not justify doing so without parental consent.

To evaluate the role of fluid and electrolyte therapy in the pathogenesis of chronic lung disease. There have been no new studies since 2000, and there are minimal data addressing this issue specifically in infants at highest risk of chronic lung disease (ie, extremely low birth weight infants). Most observational studies demonstrate a significant association between increased fluid intake or differences in measures of changes in total body water balance in the first week of life and chronic lung disease. However, a metaanalysis of three randomized, controlled clinical trials did not reveal a significant increase in the risk of chronic lung disease with higher fluid intakes. The results of two randomized, controlled trials of different sodium intakes were conflicting regarding whether increased intake led to an increased prevalence of chronic lung disease. The evidence is insufficient to conclude that fluid and electrolyte therapy plays a role in the pathogenesis of chronic lung disease. Even if fluid and electrolyte therapy does play a small role, the data are insufficient to help with decisions about what fluid and electrolyte intake in an individual infant in a specific clinical setting might reduce the risk of chronic lung disease. However, net negative water and sodium balances and the resultant contraction of the extracellular space are probably physiologic in preterm infants in the first week of life and evidence suggests that a positive water and sodium balance and expansion of the extracellular space during this period increase morbidity. It is not clear what degree of contraction is appropriate or whether varying degrees of contraction of the extracellular space alter morbidity.