Patient Presentation
Two patients came to clinic for well child care. The first was a 7-year-old male former 25 week premature infant with unilateral grade II intraventricular hemorrhage (IVH). He had problems with speech, gross motor skills and mental health issues. He was not able to speak until 3 years of age, but could now be understood easily. He also was quite slow obtaining his gross motor skills and was described as “just a little clumsy now.” He had severe attentional issues and obsessive traits that were managed with medication and behavioral interventions. Additionally he had learning problems in reading and math, but was receiving special education and behavioral therapy at school and making appropriate progress. The second patient was a 89-day-old female former 24 week premature infant with bilateral grade III IVH. She continued to need supplemental oxygen and was noted to be somewhat stiff during her examination, but was gaining good weight.
The diagnosis of former premature infants with IVH was made. These patients caused the resident and staff pediatricians to discuss neurodevelopmental outcomes of premature infants. The staff pediatrician felt he didn’t know the most current data, so together they performed a PubMed literature search. They also queried the Vermont Oxford Network (VON) as they knew this was a neonatology research network. VON did not publish the data directly but did list their research publications.
Figure 80 – Two contiguous coronal ultrasound images of the brain showing the echogenic focus of right intraventricular hemorrhage grade II involving the right germinal matrix (top image) and then extending into the superior portion of the right lateral ventricle without ventricular dilation (bottom image). The echogenic substance filling the inferior portions of both lateral ventricles in the bottom image is the patient’s normal choroid plexus.
Discussion
With the advent of multiple new technologies and the birth and maturation of neonatology as a pediatric specialty has come dramatically improved outcomes for premature and full term neonates. Mortality has decreased and more children that previously would have died, now live. Decreasing birth weight and decreasing gestational age are predictors of potential chronic neurodevelopmental problems. Other problems that premature infants face include retinopathy of prematurity, anemia, sepsis, necrotizing enterocolitis, pulmonary hypertension, and therapies such as oxygen and ototoxic drugs that are necessary for survival but that put the infant at increased risk for chronic morbidities. The infant central nervous system is particularly vulnerable and premature infants are at risk for intraventricular hemorrhage. There are 4 grades with higher numbers involving more of the brain and carrying a higher risk for morbidities. IVH grading can be reviewed here.
Learning Point
As there are many variables for survival and morbidity it is sometimes difficult to compare various research studies to determine what are the long-term neurological outcomes for premature infants with IVH.
A 2008 study of teenage patients who previously had grade IV IVH and porencephaly (N=10) found that all patients had impairments in motor skills, cognition and overall functioning. Most were ambulatory, and needed special education assistance and had social impairments.
A 2009 study of 12 year olds with previous grade III and IV IVH found that their intelligence quotient was 6-14 points lower than a control group of former premature infants without IVH, and both premature groups with and without IVH had lower intelligence quotient than full-term controls. Patients with IVH needed more school services in reading, writing and math when compared to premature controls and full term controls.
Another 2009 study of patients between 4-12 years of age with previous IVH found decreased intelligence quotients (mean of 83), abnormal behavior (47%) and abnormal executive functions (between 35-71% depending on parent or teacher report).
These data can only give a gestalt of the outcomes of premature infants with IVH. They also do not judge quality of life of the former premature infant.
Questions for Further Discussion
1. What is the current infant mortality in the United States and other countries?
2. What community and special education services are available for former premature infants in your community?
3. Where can families go to understand special education services and laws in your state?
Related Cases
- Disease: Premature Babies | Developmental Disabilities
- Symptom/Presentation: Behavior Problems | Developmental Delay | Health Maintenance and Disease Prevention | Learning Problems
- Specialty: Developmental Disabilities | Neonatology | Psychiatry and Psychology | Radiology / Nuclear Medicine / Radiation Oncology | School
- Age: Premature Newborn | School Ager
To Learn More
To view pediatric review articles on this topic from the past year check PubMed.
Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.
Information prescriptions for patients can be found at MedlinePlus for these topics: Premature Babies and Developmental Disabilities.
To view current news articles on this topic check Google News.
To view images related to this topic check Google Images.
Sherlock RL, Synnes AR, Grunau RE, Holsti L, Hubber-Richard P, Johannesen D, Whitfield MF.
Long-term outcome after neonatal intraparenchymal echodensities with porencephaly.
Arch Dis Child Fetal Neonatal Ed. 2008 Mar;93(2):F127-31.
Luu TM, Ment LR, Schneider KC, Katz KH, Allan WC, Vohr BR.
Lasting effects of preterm birth and neonatal brain hemorrhage at 12 years of age. Pediatrics. 2009 Mar;123(3):1037-44.
Roze E, Van Braeckel KN, van der Veere CN, Maathuis CG, Martijn A, Bos AF.
Functional outcome at school age of preterm infants with periventricular hemorrhagic infarction. Pediatrics. 2009 Jun;123(6):1493-500.
ACGME Competencies Highlighted by Case
2. Essential and accurate information about the patients’ is gathered.
3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
6. Information technology to support patient care decisions and patient education is used.
10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.
12. Evidence from scientific studies related to the patients’ health problems is located, appraised and assimilated.
13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.
14. Knowledge of study designs and statistical methods to appraisal clinical studies and other information on diagnostic and therapeutic effectiveness is applied.
15. Information technology to manage information, access on-line medical information and support the healthcare professional’s own education is used.
16. Learning of students and other health care professionals is facilitated.
17. A therapeutic and ethically sound relationship with patients is created and sustained.
18. Using effective nonverbal, explanatory, questioning, and writing skills, the healthcare professional uses effective listening skills and elicits and provides information.
19. The health professional works effectively with others as a member or leader of a health care team or other professional group.
Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa Children’s Hospital
Pediatric Education 