Clinical Focus

  • Neonatal-Perinatal Medicine
  • Neonatology

Academic Appointments

Administrative Appointments

  • Associate Chief for Prenatal Services, Division of Neonatal and Developmental Medicine, Stanford (2012 - Present)
  • Professor of Pediatrics, Stanford University School of Medicine (2012 - Present)
  • Professor of Obstetrics and Gynecology (by courtesy), Stanford University School of Medicine (2012 - Present)
  • Medical Director, Center for Fetal and Maternal Health, LPCH (2009 - Present)
  • Associate Professor of Pediatrics, Stanford University School of Medicine (2007 - 2012)
  • Assistant Professor of Pediatrics, Stanford University School of Medicine (2000 - 2007)
  • Clinical Senator-At-Large, Stanford University School of Medicine (2002 - 2006)

Honors & Awards

  • Co-investigator, Adrenal function & Adverse CV outcomes: An ancillary to the SUPPORT NEURO study, NICHD/ NHLBI (2013-present)
  • Principal Investigator, School Age Follow-up - The SUPPORT NEURO cohort, NICHD Neonatal Research Network (2008-present)
  • Harman Faculty Scholar, The Arline and Pete Faculty Scholar Fund (2009-present)
  • Head, Follow Up Programs, CPQCC-California Children's Services High Risk Infant Follow Up Quality of Care Initiative (2008-present)
  • Principal Investigator, Neurodevelopmental Follow-up, Stanford University site,, NICHD Neonatal Research Network (2001-present)
  • Specialized Clinical Investigator Development Award (MSCIDA), NICHD, National Institutes of Health (2004-2007)
  • Western Society for Clinical Investigation Subspecialty Award, Western Society for Pediatric Research (2003)
  • ROSE award (Recognition of Service Excellence), Lucile Salter Packard Children's Hospital at Stanford (2002, 2006)
  • Dana Foundation Grant Clinical Hypotheses Program in Imaging, Charles A. Dana Foundation (2001-2005)
  • Designate, “Pediatric Leaders for the 21st Century”, Pediatric Leadership Alliance American Academy of Pediatrics (2002)

Boards, Advisory Committees, Professional Organizations

  • Council, District IX AAP Section on Perinatal Pediatrics, Section on Perinatal Pediatrics, American Academy of Pediatrics (2008 - Present)
  • Officer and Membership Secretary, Society for Pediatric Research (2008 - Present)
  • Fellow, American Academy of Pediatrics (2005 - Present)
  • Member, American Pediatrics Society (2010 - Present)
  • SPR Representative, NIH National Child and Maternal Health Education Program Coordinating Committee (2012 - Present)
  • Chair, Member Engagement Committee, Society for Pediatric Research (2009 - 2014)

Professional Education

  • Fellowship:Stanford University School of Medicine (1999) CA
  • Residency:Stanford University School of Medicine (1996) CA
  • Internship:Stanford University School of Medicine (1993) CA
  • M.S. Epi, Stanford University, Clinical Epidemiology (2006)
  • Medical Education:Stanford University School of Medicine (1992) CA
  • M.D., Stanford University, Medicine (1992)
  • B.S., Stanford University, Biological Sciences (1987)
  • Board Certification: Neonatal-Perinatal Medicine, American Board of Pediatrics (2005)

Research & Scholarship

Current Research and Scholarly Interests

1) Early childhood neurodevelopmental outcomes, mortality and morbidities of ELBW, extremely premature, and high-risk infants; predictive clinical factors, evidence-based interventions
2) Use of advanced neuroimaging techniques in the premature and term infant; diagnostic findings, and predictors of neurodevelopmental outcomes
3) Advanced therapeutic modalities: HFOV, iNO, ECMO - implementation, indications, outcomes
4) Natural history and outcomes of complex fetal anomalies

Clinical Trials

  • Sutureless vs Sutured Gastroschisis Closure Recruiting

    This study aims to prospectively assess outcomes of sutureless versus sutured gastroschisis closure with a randomized control trial. The parameters of this trial were determined using our retrospective study as pilot data. Primary outcome measures will be time on ventilator and time to initiating enteral feeds. Other outcome measures will include cosmetic outcome, length of hospital stay and the associated rate of complications, including bowel resection, sepsis, and death.

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  • Follow-up Visit of High Risk Infants Recruiting

    The NICHD Neonatal Research Network's Follow-Up study is a multi-center cohort in which surviving extremely low birth-weight infants born in participating network centers receive neurodevelopmental, neurosensory and functional assessments at 22-26 months corrected age (Infants born prior to July 1, 2012 were seen at 18-22 months corrected age). Data regarding pregnancy and neonatal outcome are collected prospectively. The goal is to identify potential maternal and neonatal risk factors that may affect infant neurodevelopment.

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  • Optimizing (Longer, Deeper) Cooling for Neonatal Hypoxic-Ischemic Encephalopathy(HIE) Not Recruiting

    The Optimizing Cooling trial will compare four whole-body cooling treatments for infants born at 36 weeks gestational age or later with hypoxic-ischemic encephalopathy: (1) cooling for 72 hours to 33.5°C; (2) cooling for 120 hours to 33.5°C; (3) cooling for 72 hours to 32.0°C; and (4) cooling for 120 hours to 32.0°C. The objective of this study is to evaluate whether whole-body cooling initiated at less than 6 hours of age and continued for 120 hours and/or a depth at 32.0°C in will reduce death and disability at 18-22 months corrected age.

    Stanford is currently not accepting patients for this trial. For more information, please contact M Bethany Ball, (650) 725 - 8342.

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  • Laparotomy vs. Drainage for Infants With Necrotizing Enterocolitis Recruiting

    This trial will compare the effectiveness of two surgical procedures -laparotomy versus drainage - commonly used to treat necrotizing enterocolitis (NEC) or isolated intestinal perforations (IP) in extremely low birth weight infants (≤1,000 g). Infants diagnosed with NEC or IP requiring surgical intervention, will be recruited. Subjects will be randomized to receive either a laparotomy or peritoneal drainage. Primary outcome is impairment-free survival at 18-22 months corrected age.

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2013-14 Courses

Graduate and Fellowship Programs


Journal Articles

  • Outcomes of extremely preterm infants following severe intracranial hemorrhage. Journal of perinatology DAVIS, A. S., Hintz, S. R., Goldstein, R. F., Ambalavanan, N., Bann, C. M., Stoll, B. J., Bell, E. F., Shankaran, S., Laptook, A. R., Walsh, M. C., HALE, E. C., Newman, N. S., Das, A., Higgins, R. D. 2014; 34 (3): 203-208


    Objective:Severe intracranial hemorrhage (ICH) is an important prognostic variable in extremely preterm (EPT) infants. We examined imaging and clinical variables that predict outcomes in EPT infants with severe ICH.Study design:Retrospective analysis of 353 EPT infants with severe ICH. Outcomes were compared by examining: (i) unilateral vs bilateral ICH; and (ii) presence vs absence of hemorrhagic parenchymal infarction (HPI). Regression analyses identified variables associated with death or neurodevelopmental impairment (NDI).Result:Bilateral ICH and HPI had higher rates of adverse outcomes and were independently associated with death/NDI. HPI was the most important variable for infants of lower birth weight, and bilateral ICH for larger infants. For infants surviving to 36 weeks, shunt placement was most associated with death/NDI.Conclusion:Bilateral ICH and the presence of HPI in EPT infants with severe ICH are associated with death/NDI, though the importance depends on birth weight and survival to 36 weeks.

    View details for DOI 10.1038/jp.2013.162

    View details for PubMedID 24370654

  • Neurodevelopmental outcomes of extremely low birth weight infants with spontaneous intestinal perforation or surgical necrotizing enterocolitis JOURNAL OF PERINATOLOGY Wadhawan, R., Oh, W., Hintz, S. R., Blakely, M. L., Das, A., Bell, E. F., Saha, S., Laptook, A. R., Shankaran, S., Stoll, B. J., Walsh, M. C., Higgins, R. D. 2014; 34 (1): 64-70


    To determine if extremely low birth weight infants with surgical necrotizing enterocolitis have a higher risk of death or neurodevelopmental impairment and neurodevelopmental impairment among survivors (secondary outcome) at 18-22 months corrected age compared with infants with spontaneous intestinal perforation and infants without necrotizing enterocolitis or spontaneous intestinal perforation.Retrospective analysis of the Neonatal Research Network very low birth weight registry, evaluating extremely low birth weight infants born between 2000 and 2005. The study infants were designated into three groups: (1) spontaneous intestinal perforation without necrotizing enterocolitis; (2) surgical necrotizing enterocolitis (Bell's stage III); and (3) neither spontaneous intestinal perforation nor necrotizing enterocolitis. Multivariate logistic regression analysis was performed to evaluate the association between the clinical group and death or neurodevelopmental impairment, controlling for multiple confounding factors including center.Infants with surgical necrotizing enterocolitis had the highest rate of death before hospital discharge (53.5%) and death or neurodevelopmental impairment (82.3%) compared with infants in the spontaneous intestinal perforation group (39.1 and 79.3%) and no necrotizing enterocolitis/no spontaneous intestinal perforation group (22.1 and 53.3%; P<0.001). Similar results were observed for neurodevelopmental impairment among survivors. On logistic regression analysis, both spontaneous intestinal perforation and surgical necrotizing enterocolitis were associated with increased risk of death or neurodevelopmental impairment (adjusted odds ratio 2.21, 95% confidence interval (CI): 1.5, 3.2 and adjusted OR 2.11, 95% CI: 1.5, 2.9, respectively) and neurodevelopmental impairment among survivors (adjusted OR 2.17, 95% CI: 1.4, 3.2 and adjusted OR 1.70, 95% CI: 1.2, 2.4, respectively).Spontaneous intestinal perforation and surgical necrotizing enterocolitis are associated with a similar increase in the risk of death or neurodevelopmental impairment and neurodevelopmental impairment among extremely low birth weight survivors at 18-22 months corrected age.

    View details for DOI 10.1038/jp.2013.128

    View details for Web of Science ID 000329123000013

    View details for PubMedID 24135709

  • Early working memory as a racially and ethnically neutral measure of outcome in extremely preterm children at 18-22months. Early human development Lowe, J. R., Duncan, A. F., Bann, C. M., Fuller, J., Hintz, S. R., Das, A., Higgins, R. D., Watterberg, K. L. 2013; 89 (12): 1055-1061


    Difficulties with executive function have been found in preterm children, resulting in difficulties with learning and school performance.This study evaluated the relationship of early working memory as measured by object permanence items to the cognitive and language scores on the Bayley Scales-III in a cohort of children born extremely preterm.Logistic regression models were conducted to compare object permanence scores derived from the Bayley Scales-III by race/ethnicity and maternal education, controlling for medical covariates.Extremely preterm toddlers (526), who were part of a Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network's multi-center study, were evaluated at 18-22 months corrected age.Object permanence scores derived from the Bayley Developmental Scales were compared by race/ethnicity and maternal education, controlling for medical covariates.There were no significant differences in object permanence mastery and scores among the treatment groups after controlling for medical and social variables, including maternal education and race/ethnicity. Males and children with intraventricular hemorrhage, retinopathy of prematurity, and bronchopulmonary dysplasia were less likely to demonstrate object permanence mastery and had lower object permanence scores. Children who attained object permanence mastery had significantly higher Bayley Scales-III cognitive and language scores after controlling for medical and socio-economic factors.Our measure of object permanence is free of influence from race, ethnic and socio-economic factors. Adding this simple task to current clinical practice could help detect early executive function difficulties in young children.

    View details for DOI 10.1016/j.earlhumdev.2013.08.009

    View details for PubMedID 23993309

  • Apgar scores at 10 min and outcomes at 6-7 years following hypoxic-ischaemic encephalopathy ARCHIVES OF DISEASE IN CHILDHOOD-FETAL AND NEONATAL EDITION Natarajan, G., Shankaran, S., Laptook, A. R., Pappas, A., Bann, C. M., McDonald, S. A., Das, A., Higgins, R. D., Hintz, S. R., Vohr, B. R. 2013; 98 (6): F473-F479


    To determine the association between 10 min Apgar scores and 6-7-year outcomes in children with perinatal hypoxic-ischaemic encephalopathy (HIE) enrolled in the National Institute of Child Health and Human Development Neonatal Research Network (NICHD NRN) whole body cooling randomised controlled trial (RCT).Evaluations at 6-7 years included the Wechsler Preschool and Primary Scale of Intelligence III or Wechsler Intelligence Scale for Children IV and Gross Motor Functional Classification Scale. Primary outcome was death/moderate or severe disability. Logistic regression was used to examine the association between 10 min Apgar scores and outcomes after adjusting for birth weight, gestational age, gender, outborn status, hypothermia treatment and centre.In the study cohort (n=174), 64/85 (75%) of those with 10 min Apgar score of 0-3 had death/disability compared with 40/89 (45%) of those with scores >3. Each point increase in 10 min Apgar scores was associated with a significantly lower adjusted risk of death/disability, death, death/IQ <70, death/cerebral palsy (CP) and disability, IQ<70 and CP among survivors (all p<0.05). Among the 24 children with a 10 min Apgar score of 0, five (20.8%) survived without disability. The risk-adjusted probabilities of death/disability were significantly lower in cooled infants with Apgar scores of 0-3; there was no significant interaction between cooling and Apgar scores (p=0.26).Among children with perinatal HIE enrolled in the NICHD cooling RCT, 10 min Apgar scores were significantly associated with school-age outcomes. A fifth of infants with 10 min Apgar score of 0 survived without disability to school age, suggesting the need for caution in limiting resuscitation to a specified duration.

    View details for DOI 10.1136/archdischild-2013-303692

    View details for Web of Science ID 000325556000003

    View details for PubMedID 23896791

  • Neurodevelopmental outcome of extremely low birth weight infants with Candida infection. journal of pediatrics Adams-Chapman, I., Bann, C. M., Das, A., Goldberg, R. N., Stoll, B. J., Walsh, M. C., Sánchez, P. J., Higgins, R. D., Shankaran, S., Watterberg, K. L., Duara, S., Miller, N. A., Heyne, R. J., Peralta-Carcelen, M., Goldstein, R. F., Steichen, J. J., Bauer, C. R., Hintz, S. R., Evans, P. W., Acarregui, M. J., Myers, G. J., Vohr, B. R., Wilson-Costello, D. E., Pappas, A., Vaucher, Y. E., Ehrenkranz, R. A., McGowan, E. C., Dillard, R. G., Fuller, J., Benjamin, D. K. 2013; 163 (4): 961-967 e3


    OBJECTIVE: Candida remains an important cause of late-onset infection in preterm infants. Mortality and neurodevelopmental outcome of extremely low birth weight (ELBW) infants enrolled in the Candida study were evaluated based on infection status. STUDY DESIGN: ELBW infants born at Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network (NRN) centers between March 2004 and July 2007 who were screened for suspected sepsis were eligible for inclusion in the Candida study. Primary outcome data for neurodevelopmental impairment (NDI) or death were available for 1317 of the 1515 infants (87%) enrolled in the Candida study. The Bayley Scales of Infant Development-II or -III was administered at 18 months' adjusted age. A secondary comparison was performed with 864 infants enrolled in the NRN Generic Database during the same cohort who were never screened for sepsis and therefore not eligible for the Candida study. RESULTS: Among ELBW infants enrolled in the Candida study, 31% with Candida and 31% with late-onset non-Candida sepsis had NDI at 18 months. Infants with Candida sepsis and/or meningitis had an increased risk of death and were more likely to have the composite outcome of death and/or NDI compared with uninfected infants in adjusted analysis. Compared with infants in the NRN registry never screened for sepsis, overall risk for death were similar but those with Candida infection were more likely to have NDI (OR 1.83, 95% CI 1.01-3.33, P = .047). CONCLUSIONS: In this cohort of ELBW infants, those with infection and/or meningitis were at increased risk for death and/or NDI. This risk was highest among those with Candida sepsis and/or meningitis.

    View details for DOI 10.1016/j.jpeds.2013.04.034

    View details for PubMedID 23726546

  • Cerebral Palsy and Growth Failure at 6 to 7 Years PEDIATRICS Vohr, B. R., Stephens, B. E., McDonald, S. A., Ehrenkranz, R. A., Laptook, A. R., Pappas, A., Hintz, S. R., Shankaran, S., Higgins, R. D., Das, A. 2013; 132 (4): E905-E914


    To evaluate the association between severity of cerebral palsy (CP) and growth to 6 to 7 years of age among children with moderate to severe (Mod/Sev) hypoxic ischemic encephalopathy (HIE). It was hypothesized that children with Mod/Sev CP would have poorer growth, lower cognitive scores, and increased rehospitalization rates compared with children with no CP (No CP).Among 115 of 122 surviving children followed in the hypothermia trial for neonatal HIE, growth parameters and neurodevelopmental status at 18 to 22 months and 6 to 7 years were available. Group comparisons (Mod/Sev CP and No CP) with unadjusted and adjusted analyses for growth <10th percentile and z scores by using Fisher's exact tests and regression modeling were conducted.Children with Mod/Sev CP had high rates of slow growth and cognitive and motor impairment and rehospitalizations at 18 to 22 months and 6 to 7 years. At 6 to 7 years of age, children with Mod/Sev CP had increased rates of growth parameters <10th percentile compared with those with No CP (weight, 57% vs 3%; height, 70% vs 2%; and head circumference, 82% vs 13%; P < .0001). Increasing severity of slow growth was associated with increasing age (P < .04 for weight, P < .001 for length, and P < .0001 for head circumference). Gastrostomy feeds were associated with better growth.Term children with HIE who develop Mod/Sev CP have high and increasing rates of growth <10th percentile by 6 to 7 years of age. These findings support the need for close medical and nutrition management of children with HIE who develop CP.

    View details for DOI 10.1542/peds.2012-3915

    View details for Web of Science ID 000325095400012

    View details for PubMedID 24019415

  • Neurodevelopmental outcomes of extremely low-gestational-age neonates with low-grade periventricular-intraventricular hemorrhage. JAMA pediatrics Payne, A. H., Hintz, S. R., Hibbs, A. M., Walsh, M. C., Vohr, B. R., Bann, C. M., Wilson-Costello, D. E. 2013; 167 (5): 451-459


    Low-grade periventricular-intraventricular hemorrhage is a common neurologic morbidity among extremely low-gestational-age neonates, yet the outcomes associated with this morbidity are not fully understood. In a contemporary multicenter cohort, we evaluated the impact of such hemorrhages on early (18-22 month) neurodevelopmental outcomes of extremely premature infants.To compare neurodevelopmental outcomes at 18 to 22 months' corrected age for extremely low-gestational-age infants with low-grade (grade 1 or 2) periventricular-intraventricular hemorrhage with those of infants with either no hemorrhage or severe (grade 3 or 4) hemorrhage demonstrated on cranial ultrasonography.Longitudinal observational study.Sixteen centers of the Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network.A total of 1472 infants born at less than 27 weeks' gestational age between January 1, 2006, and December 31, 2008, with ultrasonography results within the first 28 days of life and surviving to 18 to 22 months with complete follow-up assessments were eligible.Low-grade periventricular-intraventricular hemorrhage.Outcomes included cerebral palsy; gross motor functional limitation; cognitive and language scores according to the Bayley Scales of Infant Development, 3rd Edition; and composite measures of neurodevelopmental impairment. Regression modeling evaluated the association of hemorrhage severity with adverse outcomes while controlling for potentially confounding variables and center differences.Low-grade hemorrhage was not associated with significant differences in unadjusted or adjusted risk of any adverse neurodevelopmental outcome compared with infants without hemorrhage. Compared with low-grade hemorrhage, severe hemorrhage was associated with decreased adjusted continuous cognitive (?, -3.91 [95% CI, -6.41 to -1.42]) and language (?, -3.19 [-6.19 to -0.19]) scores as well as increased odds of each adjusted categorical outcome except severe cognitive impairment (odds ratio [OR], 1.46 [0.74 to 2.88]) and mild language impairment (OR, 1.35 [0.88 to 2.06]).At 18 to 22 months, the neurodevelopmental outcomes of extremely low-gestational-age infants with low-grade periventricular-intraventricular hemorrhage are not significantly different from those without hemorrhage. Additional study at school age and beyond would be informative.

    View details for DOI 10.1001/jamapediatrics.2013.866

    View details for PubMedID 23460139

  • Neurodevelopmental Outcomes in the Early CPAP and Pulse Oximetry Trial NEW ENGLAND JOURNAL OF MEDICINE Vaucher, Y. E., Peralta-Carcelen, M., Finer, N. N., Carlo, W. A., Gantz, M. G., Walsh, M. C., Laptook, A. R., Yoder, B. A., Faix, R. G., Das, A., Schibler, K., Rich, W., Newman, N. S., Vohr, B. R., Yolton, K., Heyne, R. J., Wilson-Costello, D. E., Evans, P. W., Goldstein, R. F., Acarregui, M. J., Adams-Chapman, I., Pappas, A., Hintz, S. R., Poindexter, B., Dusick, A. M., McGowan, E. C., Ehrenkranz, R. A., Bodnar, A., Bauer, C. R., Fuller, J., O'Shea, T. M., Myers, G. J., Higgins, R. D. 2012; 367 (26): 2495-2504


    Previous results from our trial of early treatment with continuous positive airway pressure (CPAP) versus early surfactant treatment in infants showed no significant difference in the outcome of death or bronchopulmonary dysplasia. A lower (vs. higher) target range of oxygen saturation was associated with a lower rate of severe retinopathy but higher mortality. We now report longer-term results from our prespecified hypotheses.Using a 2-by-2 factorial design, we randomly assigned infants born between 24 weeks 0 days and 27 weeks 6 days of gestation to early CPAP with a limited ventilation strategy or early surfactant administration and to lower or higher target ranges of oxygen saturation (85 to 89% or 91 to 95%). The primary composite outcome for the longer-term analysis was death before assessment at 18 to 22 months or neurodevelopmental impairment at 18 to 22 months of corrected age.The primary outcome was determined for 1234 of 1316 enrolled infants (93.8%); 990 of the 1058 surviving infants (93.6%) were evaluated at 18 to 22 months of corrected age. Death or neurodevelopmental impairment occurred in 27.9% of the infants in the CPAP group (173 of 621 infants), versus 29.9% of those in the surfactant group (183 of 613) (relative risk, 0.93; 95% confidence interval [CI], 0.78 to 1.10; P=0.38), and in 30.2% of the infants in the lower-oxygen-saturation group (185 of 612), versus 27.5% of those in the higher-oxygen-saturation group (171 of 622) (relative risk, 1.12; 95% CI, 0.94 to 1.32; P=0.21). Mortality was increased with the lower-oxygen-saturation target (22.1%, vs. 18.2% with the higher-oxygen-saturation target; relative risk, 1.25; 95% CI, 1.00 to 1.55; P=0.046).We found no significant differences in the composite outcome of death or neurodevelopmental impairment among extremely premature infants randomly assigned to early CPAP or early surfactant administration and to a lower or higher target range of oxygen saturation. (Funded by the Eunice Kennedy Shriver National Institute of Child Health and Human Development and the National Heart, Lung, and Blood Institute; SUPPORT number, NCT00233324.).

    View details for DOI 10.1056/NEJMoa1208506

    View details for Web of Science ID 000312714200007

    View details for PubMedID 23268664

  • Infants with Prenatally Diagnosed Anomalies Special Approaches to Preparation and Resuscitation CLINICS IN PERINATOLOGY Colby, C. E., Carey, W. A., Blumenfeld, Y. J., Hintz, S. R. 2012; 39 (4): 871-887


    When a fetal anomaly is suspected, a multidisciplinary approach to diagnosis, counseling, pregnancy management, surveillance, delivery planning, and neonatal care is critical to creating a comprehensive management plan. This article provides a basic framework for integrating prenatal diagnostic and maternal-fetal care considerations, delivery planning, special resuscitation needs, and immediate and later neonatal care and evaluation into developing a thoughtful management plan for infants with prenatally diagnosed complex anomalies including congenital heart disease, intrathoracic masses, fetal airway obstruction, neural tube defects, abdominal wall defects, and skeletal dysplasia.

    View details for DOI 10.1016/j.clp.2012.09.012

    View details for Web of Science ID 000312623900011

    View details for PubMedID 23164184

  • Brain injury following trial of hypothermia for neonatal hypoxic-ischaemic encephalopathy ARCHIVES OF DISEASE IN CHILDHOOD-FETAL AND NEONATAL EDITION Shankaran, S., Barnes, P. D., Hintz, S. R., Laptook, A. R., Zaterka-Baxter, K. M., McDonald, S. A., Ehrenkranz, R. A., Walsh, M. C., Tyson, J. E., Donovan, E. F., Goldberg, R. N., Bara, R., Das, A., Finer, N. N., Sanchez, P. J., Poindexter, B. B., Van Meurs, K. P., Carlo, W. A., Stoll, B. J., Duara, S., Guillet, R., Higgins, R. D. 2012; 97 (6): F398-F404


    The objective of our study was to examine the relationship between brain injury and outcome following neonatal hypoxic-ischaemic encephalopathy treated with hypothermia.Neonatal MRI scans were evaluated in the National Institute of Child Health and Human Development (NICHD) randomised controlled trial of whole-body hypothermia and each infant was categorised based upon the pattern of brain injury on the MRI findings. Brain injury patterns were assessed as a marker of death or disability at 18-22 months of age.Scans were obtained on 136 of 208 trial participants (65%); 73 in the hypothermia and 63 in the control group. Normal scans were noted in 38 of 73 infants (52%) in the hypothermia group and 22 of 63 infants (35%) in the control group. Infants in the hypothermia group had fewer areas of infarction (12%) compared to infants in the control group (22%). Fifty-one of the 136 infants died or had moderate or severe disability at 18 months. The brain injury pattern correlated with outcome of death or disability and with disability among survivors. Each point increase in the severity of the pattern of brain injury was independently associated with a twofold increase in the odds of death or disability.Fewer areas of infarction and a trend towards more normal scans were noted in brain MRI following whole-body hypothermia. Presence of the NICHD pattern of brain injury is a marker of death or moderate or severe disability at 18-22 months following hypothermia for neonatal encephalopathy.

    View details for DOI 10.1136/archdischild-2011-301524

    View details for Web of Science ID 000311022800003

    View details for PubMedID 23080477

  • Screening for Autism Spectrum Disorders in Extremely Preterm Infants JOURNAL OF DEVELOPMENTAL AND BEHAVIORAL PEDIATRICS Stephens, B. E., Bann, C. M., Watson, V. E., Sheinkopf, S. J., Peralta-Carcelen, M., Bodnar, A., Yolton, K., Goldstein, R. F., Dusick, A. M., Wilson-Costello, D. E., Acarregui, M. J., Pappas, A., Adams-Chapman, I., McGowan, E. C., Heyne, R. J., Hintz, S. R., Ehrenkranz, R. A., Fuller, J., Das, A., Higgins, R. D., Vohr, B. R. 2012; 33 (7): 535-541


    Extremely preterm (EP) infants screen positive for autism spectrum disorders (ASD) at high rates. However, it is not clear whether this is because of high rates of ASD in EPs or to high rates of false-positive screens for ASD in children with a high rate of underlying neurodevelopmental impairments. Combining a parent questionnaire designed to distinguish developmental delay from ASD with direct observation of infant behavior may more accurately screen for ASD in EPs.To determine rates of positive screen for ASD at 18 to 22 months(m) in EPs using 3 screens; to determine factors associated with a positive screen.Five hundred fifty-four infants born <27 weeks were screened at 18 to 22 m using the Pervasive Developmental Disorders Screening test, second edition Stage 2, and the response to name and response to joint attention items from the Autism Diagnostic Observation Schedule. Infants with severe cerebral palsy, deafness, and blindness were excluded. Associations between positive screen and neonatal/ infant characteristics were determined.Of 554 infants, 113 (20%) had ? 1 positive screen. 10% had a positive Pervasive Developmental Disorders Screening test, second edition, 6% response to name, 9% response to joint attention; in only 1 % all 3 screens were positive. Positive screen was associated with male gender, more hospital days, white race, lower maternal education, abnormal behavioral scores, and cognitive/ language delay.The use of 3 screens for ASD in EPs results in higher screen positive rates than use of 1 screen alone. Diagnostic confirmation is needed before true rates of ASD in EPs are known.

    View details for DOI 10.1097/DBP.0b013e31825fd0af

    View details for Web of Science ID 000308668400002

    View details for PubMedID 22926660

  • Are Outcomes of Extremely Preterm Infants Improving? Impact of Bayley Assessment on Outcomes JOURNAL OF PEDIATRICS Vohr, B. R., Stephens, B. E., Higgins, R. D., Bann, C. M., Hintz, S. R., Das, A., Newman, J. E., Peralta-Carcelen, M., Yolton, K., Dusick, A. M., Evans, P. W., Goldstein, R. F., Ehrenkranz, R. A., Pappas, A., Adams-Chapman, I., Wilson-Costello, D. E., Bauer, C. R., Bodnar, A., Heyne, R. J., Vaucher, Y. E., Dillard, R. G., Acarregui, M. J., McGowan, E. C., Myers, G. J., Fuller, J. 2012; 161 (2): 222-?


    To compare 18- to 22-month cognitive scores and neurodevelopmental impairment (NDI) in 2 time periods using the National Institute of Child Health and Human Development's Neonatal Research Network assessment of extremely low birth weight infants with the Bayley Scales of Infant Development, Second Edition (Bayley II) in 2006-2007 (period 1) and using the Bayley Scales of Infant and Toddler Development, Third Edition (Bayley III), with separate cognitive and language scores, in 2008-2011 (period 2).Scores were compared with bivariate analysis, and regression analyses were run to identify differences in NDI rates.Mean Bayley III cognitive scores were 11 points higher than mean Bayley II cognitive scores. The NDI rate was reduced by 70% (from 43% in period 1 to 13% in period 2; P < .0001). Multivariate analyses revealed that Bayley III contributed to a decreased risk of NDI by 5 definitions: cognitive score <70 and <85, cognitive or language score <70; cognitive or motor score <70, and cognitive, language, or motor score <70 (P < .001).Whether the Bayley III is overestimating cognitive performance or whether it is a more valid assessment of emerging cognitive skills than the Bayley II is uncertain. Because the Bayley III identifies significantly fewer children with disability, it is recommended that all extremely low birth weight infants be offered early intervention services at the time of discharge from the neonatal intensive care unit, and that Bayley scores be interpreted with caution.

    View details for DOI 10.1016/j.jpeds.2012.01.057

    View details for Web of Science ID 000306693800013

    View details for PubMedID 22421261

  • Childhood Outcomes after Hypothermia for Neonatal Encephalopathy NEW ENGLAND JOURNAL OF MEDICINE Shankaran, S., Pappas, A., McDonald, S. A., Vohr, B. R., Hintz, S. R., Epi, M. S., Yolton, K., Gustafson, K. E., Leach, T. M., Green, C., Bara, R., Huitema, C. M., Ehrenkranz, R. A., Tyson, J. E., Das, A., Hammond, J., Peralta-Carcelen, M., Evans, P. W., Heyne, R. J., Wilson-Costello, D. E., Vaucher, Y. E., Bauer, C. R., Dusick, A. M., Adams-Chapman, I., Goldstein, R. F., Guillet, R., Papile, L., Higgins, R. D. 2012; 366 (22): 2085-2092


    We previously reported early results of a randomized trial of whole-body hypothermia for neonatal hypoxic-ischemic encephalopathy showing a significant reduction in the rate of death or moderate or severe disability at 18 to 22 months of age. Long-term outcomes are now available.In the original trial, we assigned infants with moderate or severe encephalopathy to usual care (the control group) or whole-body cooling to an esophageal temperature of 33.5°C for 72 hours, followed by slow rewarming (the hypothermia group). We evaluated cognitive, attention and executive, and visuospatial function; neurologic outcomes; and physical and psychosocial health among participants at 6 to 7 years of age. The primary outcome of the present analyses was death or an IQ score below 70.Of the 208 trial participants, primary outcome data were available for 190. Of the 97 children in the hypothermia group and the 93 children in the control group, death or an IQ score below 70 occurred in 46 (47%) and 58 (62%), respectively (P=0.06); death occurred in 27 (28%) and 41 (44%) (P=0.04); and death or severe disability occurred in 38 (41%) and 53 (60%) (P=0.03). Other outcome data were available for the 122 surviving children, 70 in the hypothermia group and 52 in the control group. Moderate or severe disability occurred in 24 of 69 children (35%) and 19 of 50 children (38%), respectively (P=0.87). Attention-executive dysfunction occurred in 4% and 13%, respectively, of children receiving hypothermia and those receiving usual care (P=0.19), and visuospatial dysfunction occurred in 4% and 3% (P=0.80).The rate of the combined end point of death or an IQ score of less than 70 at 6 to 7 years of age was lower among children undergoing whole-body hypothermia than among those undergoing usual care, but the differences were not significant. However, hypothermia resulted in lower death rates and did not increase rates of severe disability among survivors. (Funded by the National Institutes of Health and the Eunice Kennedy Shriver NICHD Neonatal Research Network; number, NCT00005772.).

    View details for DOI 10.1056/NEJMoa1112066

    View details for Web of Science ID 000304613400008

    View details for PubMedID 22646631

  • Ventricular Access Devices Are Safe and Effective in the Treatment of Posthemorrhagic Ventricular Dilatation prior to Shunt Placement PEDIATRIC NEUROSURGERY Tian, A. G., Hintz, S. R., Cohen, R. S., Edwards, M. S. 2012; 48 (1): 13-20


    Intraventricular hemorrhage of prematurity (IVH) is a diagnosis that has become more frequent in recent years. Advances in medical care have led to survival of increasingly premature infants, as well as infants with more complex medical conditions. Treatment with a ventricular access device (VAD) was reported almost 3 decades ago; however, it is unclear how effective this treatment is in the current population of premature infants. At our institution (from 2004 to present), we treat posthemorrhagic hydrocephalus (PHH) with a VAD. In order to look at safety and efficacy, we retrospectively combed the medical records of premature children, admitted to Lucile Packard Children's Hospital from January 2005 to December 2009, and identified 310 premature children with IVH. Of these, 28 children required treatment for PHH with a VAD. There were no infections associated with placement of these devices and a very low rate of other complications, such as need for repositioning (7.41%) or replacement (3.75%). Our data show that treatment with a VAD is very safe, with few complications and can be used to treat PHH in this very complex infant population.

    View details for DOI 10.1159/000337876

    View details for Web of Science ID 000309885700003

    View details for PubMedID 22832699

  • Newborn with prenatally diagnosed choroidal fissure cyst and panhypopituitarism and review of the literature. AJP reports Chitkara, R., Rajani, A., Bernstein, J., Shah, S., Hahn, J. S., Barnes, P., Hintz, S. R. 2011; 1 (2): 111-114


    Little has been reported on fetal diagnosis of choroidal fissure cysts and prediction of the clinical complications that can result. We describe the case of a near-term male infant with prenatally diagnosed choroidal fissure cyst and bilateral clubfeet. His prolonged course in the neonatal intensive care nursery was marked by severe panhypopituitarism, late-onset diabetes insipidus, placement of a cystoperitoneal shunt, and episodes of sepsis. Postnatal genetic evaluation also revealed an interstitial deletion involving most of band 10q26.12 and the proximal half of band 10q26.13. The patient had multiple readmissions for medical and surgical indications and died at 6 months of age. This case represents the severe end of the spectrum of medical complications for children with choroidal fissure cysts. It highlights not only the importance of comprehensive evaluation and multidisciplinary management and counseling in such cases, but also the need for heightened vigilance in these patients.

    View details for DOI 10.1055/s-0031-1293512

    View details for PubMedID 23705098

  • Is phototherapy exposure associated with better or worse outcomes in 501-to 1000-g-birth-weight infants? ACTA PAEDIATRICA Hintz, S. R., Stevenson, D. K., Yao, Q., Wong, R. J., Das, A., Van Meurs, K. P., Morris, B. H., Tyson, J. E., Oh, W., Poole, W. K., Phelps, D. L., McDavid, G. E., Grisby, C., Higgins, R. D. 2011; 100 (7): 960-965


    ?To compare risk-adjusted outcomes at 18- to 22-month-corrected age for extremely low birth weight (ELBW) infants who never received phototherapy (NoPTx) to those who received any phototherapy (PTx) in the NICHD Neonatal Research Network randomized trial of Aggressive vs. Conservative Phototherapy.Outcomes at 18 to 22-month-corrected age included death, neurodevelopmental impairment (NDI) and Bayley Scales Mental Developmental Index (MDI). Regression models evaluated the independent association of PTx with adverse outcomes controlling for centre and other potentially confounding variables.Of 1972 infants, 216 were NoPTx and 1756 were PTx. For the entire 501- to 1000-g-BW cohort, PTx was not independently associated with death or NDI (OR 0.85, 95% CI: 0.60-1.20), death or adverse neurodevelopmental endpoints. However, among infants 501-750 g BW, the rate of significant developmental impairment with MDI?

    View details for DOI 10.1111/j.1651-2227.2011.02175.x

    View details for Web of Science ID 000291224200021

    View details for PubMedID 21272067

  • Improved outcomes with a standardized feeding protocol for very low birth weight infants JOURNAL OF PERINATOLOGY McCallie, K. R., Lee, H. C., Mayer, O., Cohen, R. S., Hintz, S. R., Rhine, W. D. 2011; 31: S61-S67


    The objective of this study was to evaluate the impact of a standardized enteral feeding protocol for very low birth weight (VLBW) infants on nutritional, clinical and growth outcomes.Retrospective analysis of VLBW cohorts 9 months before and after initiation of a standardized feeding protocol consisting of 6-8 days of trophic feedings, followed by an increase of 20?ml/kg/day. The primary outcome was days to reach full enteral feeds defined as 160?ml/kg/day. Secondary outcomes included rates of necrotizing enterocolitis and culture-proven sepsis, days of parenteral nutrition and growth end points.Data were analyzed on 147 VLBW infants who received enteral feedings, 83 before ('Before') and 64 subsequent to ('After') feeding protocol initiation. Extremely low birth weight (ELBW) infants in the After group attained enteral volumes of 120?ml/kg/day (43.9 days Before vs 32.8 days After, P=0.02) and 160?ml/kg/day (48.5 days Before vs 35.8 days After, P=0.02) significantly faster and received significantly fewer days of parenteral nutrition (46.2 days Before vs 31.3 days After, P=0.01). Necrotizing enterocolitis decreased in the After group among VLBW (15/83, 18% Before vs 2/64, 3% After, P=0.005) and ELBW infants (11/31, 35% Before vs 2/26, 8% After, P=0.01). Late-onset sepsis decreased significantly in the After group (26/83, 31% Before vs 6/64, 9% After, P=0.001). Excluding those with weight <3rd percentile at birth, the proportion with weight <3rd percentile at discharge decreased significantly after protocol initiation (35% Before vs 17% After, P=0.03).These data suggest that implementation of a standardized feeding protocol for VLBW infants results in earlier successful enteral feeding without increased rates of major morbidities.

    View details for DOI 10.1038/jp.2010.185

    View details for Web of Science ID 000289236900010

    View details for PubMedID 21448207

  • Early-Childhood Neurodevelopmental Outcomes Are Not Improving for Infants Born at < 25 Weeks' Gestational Age PEDIATRICS Hintz, S. R., Kendrick, D. E., Wilson-Costello, D. E., Das, A., Bell, E. F., Vohr, B. R., Higgins, R. D. 2011; 127 (1): 62-70


    We compared neurodevelopmental outcomes at 18 to 22 months' corrected age of infants born with extremely low birth weight at an estimated gestational age of <25 weeks during 2 periods: 1999-2001 (epoch 1) and 2002-2004 (epoch 2).We conducted a multicenter, retrospective analysis of the Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network. Perinatal and neonatal variables and outcomes were compared between epochs. Neurodevelopmental outcomes at 18 to 22 months' corrected age were evaluated with neurologic exams and Bayley Scales of Infant Development II. Logistic regression analyses determined the independent risk of epoch for adverse outcomes.Infant survival was similar between epochs (epoch 1, 35.4%, vs epoch 2, 32.3%; P = .09). A total of 411 of 452 surviving infants in epoch 1 and 405 of 438 surviving infants in epoch 2 were evaluated at 18 to 22 months' corrected age. Cesarean delivery (P = .03), surgery for patent ductus arteriosus (P = .004), and late sepsis (P = .01) were more common in epoch 2, but postnatal steroid use was dramatically reduced (63.5% vs 32.8%; P < .0001). Adverse outcomes at 18 to 22 months' corrected age were common in both epochs. Moderate-to-severe cerebral palsy was diagnosed in 11.1% of surviving infants in epoch 1 and 14.9% in epoch 2 (adjusted odds ratio [OR]: 1.52 [95% confidence interval (CI): 0.86-2.71]; P = .15), the Mental Developmental Index was <70 in 44.9% in epoch 1 and 51% in epoch 2 (OR: 1.30 [95% CI: 0.91-1.87]; P = .15), and neurodevelopmental impairment was diagnosed in 50.1% of surviving infants in epoch 1 and 58.7% in epoch 2 (OR: 1.4 [95% CI: 0.98-2.04]; P = .07).Early-childhood outcomes for infants born at <25 weeks' estimated gestational age were unchanged between the 2 periods.

    View details for DOI 10.1542/peds.2010-1150

    View details for Web of Science ID 000285782200046

    View details for PubMedID 21187312

  • Seizures in Extremely Low Birth Weight Infants Are Associated with Adverse Outcome JOURNAL OF PEDIATRICS Davis, A. S., Hintz, S. R., Van Meurs, K. P., Li, L., Das, A., Stoll, B. J., Walsh, M. C., Pappas, A., Bell, E. F., Laptook, A. R., Higgins, R. D. 2010; 157 (5): 720-U47


    To examine risk factors for neonatal clinical seizures and to determine the independent association with death or neurodevelopmental impairment (NDI) in extremely low birth weight (ELBW) infants.A total of 6499 ELBW infants (401-1000 g) surviving to 36 weeks postmenstrual age (PMA) were included in this retrospective study. Unadjusted comparisons were performed between infants with (n = 414) and without (n = 6085) clinical seizures during the initial hospitalization. Using multivariate logistic regression modeling, we examined the independent association of seizures with late death (after 36 weeks PMA) or NDI after controlling for multiple demographic, perinatal, and neonatal variables.Infants with clinical seizures had a greater proportion of neonatal morbidities associated with poor outcome, including severe intraventricular hemorrhage, sepsis, meningitis, and cystic periventricular leukomalacia (all P < .01). Survivors were more likely to have NDI or moderate-severe cerebral palsy at 18 to 22 months corrected age (both P < .01). After adjusting for multiple confounders, clinical seizures remained significantly associated with late death or NDI (odds ratio, 3.15; 95% CI, 2.37-4.19).ELBW infants with clinical seizures are at increased risk for adverse neurodevelopmental outcome, independent of multiple confounding factors.

    View details for DOI 10.1016/j.jpeds.2010.04.065

    View details for Web of Science ID 000283045900008

    View details for PubMedID 20542294

  • Prediction of Death for Extremely Premature Infants in a Population-Based Cohort PEDIATRICS Lee, H. C., Green, C., Hintz, S. R., Tyson, J. E., Parikh, N. A., Langer, J., Gould, J. B. 2010; 126 (3): E644-E650


    Although gestational age (GA) is often used as the primary basis for counseling and decision-making for extremely premature infants, a study of tertiary care centers showed that additional factors could improve prediction of outcomes. Our objective was to determine how such a model could improve predictions for a population-based cohort.From 2005 to 2008, data were collected prospectively for the California Perinatal Quality Care Collaborative, which encompasses 90% of NICUs in California. For infants born at GAs of 22 to 25 weeks, we assessed the ability of the Eunice Kennedy Shriver National Institute of Child Health and Human Development 5-factor model to predict survival rates, compared with a model using GA alone.In the study cohort of 4527 infants, 3647 received intensive care. Survival rates were 53% for the whole cohort and 66% for infants who received intensive care. In multivariate analyses of data for infants who received intensive care, prenatal steroid exposure, female sex, singleton birth, and higher birth weight (per 100-g increment) were each associated with a reduction in the risk of death before discharge similar to that for a 1-week increase in GA. The multivariate model increased the ability to group infants in the highest and lowest risk categories (mortality rates of >80% and <20%, respectively).In a population-based cohort, the addition of prenatal steroid exposure, sex, singleton or multiple birth, and birth weight to GA allowed for improved prediction of rates of survival to discharge for extremely premature infants.

    View details for DOI 10.1542/peds.2010-0097

    View details for Web of Science ID 000281535700047

    View details for PubMedID 20713479

  • A National Survey of Pediatric Residents and Delivery Room Training Experience JOURNAL OF PEDIATRICS Lee, H. C., Chitkara, R., Halamek, L. P., Hintz, S. R. 2010; 157 (1): 158-U211


    To investigate current delivery room training experience in US pediatric residency programs and the relationship between volume of delivery room training and confidence in neonatal resuscitation skills.Links to a web-based survey were sent to pediatric residency programs and distributed to residents. The survey concerned delivery room attendance during training and comfort level in leading neonatal resuscitation for various scenarios. Comfort level was rated on a 1 to 9 scale. Mixed models accounted for residency programs as random effects.For PL-3s, the mean number of deliveries attended was 60 (standard deviation, 43), ranging from 13 to 143 deliveries for individual residency programs. Residents' confidence level in leading neonatal resuscitation was higher when attending more deliveries, with 90.3% of those attending>48 deliveries having average score 5 or greater vs 51.5% of those attending<21 deliveries. Higher attendance also correlated with confidence in endotracheal intubation and umbilical line placement.Wide variability existed within and among residency programs in number of deliveries attended. Volume of experience correlated with confidence in leading neonatal resuscitation and related procedural skills.

    View details for DOI 10.1016/j.jpeds.2010.01.029

    View details for Web of Science ID 000278649200037

    View details for PubMedID 20304418

  • Aluminum Content of Parenteral Nutrition in Neonates: Measured Versus Calculated Levels JOURNAL OF PEDIATRIC GASTROENTEROLOGY AND NUTRITION Poole, R. L., Schiff, L., Hintz, S. R., Wong, A., Mackenzie, N., Kerner, J. A. 2010; 50 (2): 208-211


    Aluminum (Al) is associated with significant central nervous system toxicity and bone and liver damage. Because Al is a contaminant of parenteral nutrition (PN) components including calcium and phosphate additives, premature infants are at potentially high risk for toxicity. The US Food and Drug Administration (FDA) has mandated PN component product labeling and recommended maximum Al daily exposure limits. The objective of this article is to determine the actual Al content of neonatal PN solutions, compare these values to the calculated amounts from manufacturers' PN product labels, and ascertain whether the actual Al exposure exceeds the FDA recommended maximum of 5 microg . kg(-1) . day(-1).Samples from 40 neonatal patient PN solutions were selected for sampling and Al content determination. Samples were also taken from 16 manufacturer's component products used in PN formulation. All of the samples were sent to Mayo Laboratories for Al content measurement. The calculated Al concentrations in PN samples were determined from the manufacturer's labeled content.Both measured and calculated Al concentrations exceeded the FDA recommended safe limit of <5 microg . kg(-1) . day(-1). The actual measured Al content was significantly lower than the calculated Al content in both the patient PN solutions and the component product samples.Al exposure exceeded the FDA recommended maximum limit for all patient samples; however, the actual measured Al content of all the samples was significantly less than the calculated Al content based on manufacturer's labels. These findings suggest that manufacturers label their products with actual Al content at the time of product release rather than at time of expiration. Periodic monitoring of Al levels should be considered with prolonged PN therapy. Changes in manufacturing processes, including the use of better raw materials, are essential to reduce Al contamination to meet FDA mandates.

    View details for DOI 10.1097/MPG.0b013e3181aed70b

    View details for Web of Science ID 000273994000018

    View details for PubMedID 20038851

  • Predicting Time to Hospital Discharge for Extremely Preterm Infants PEDIATRICS Hintz, S. R., Bann, C. M., Ambalavanan, N., Cotten, M., Das, A., Higgins, R. D. 2010; 125 (1): E146-E154


    As extremely preterm infant mortality rates have decreased, concerns regarding resource use have intensified. Accurate models for predicting time to hospital discharge could aid in resource planning, family counseling, and stimulate quality-improvement initiatives.To develop, validate, and compare several models for predicting the time to hospital discharge for infants <27 weeks' estimated gestational age, on the basis of time-dependent covariates as well as the presence of 5 key risk factors as predictors.We conducted a retrospective analysis of infants <27 weeks' estimated gestational age who were born between July 2002 and December 2005 and survived to discharge from a Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network site. Time to discharge was modeled as continuous (postmenstrual age at discharge) and categorical (early and late discharge) variables. Three linear and logistic regression models with time-dependent covariate inclusion were developed (perinatal factors only, perinatal + early-neonatal factors, and perinatal + early-neonatal + later factors). Models for early and late discharge that used the cumulative presence of 5 key risk factors as predictors were also evaluated. Predictive capabilities were compared by using the coefficient of determination (R(2)) for the linear models and the area under the curve (AUC) of the receiver operating characteristic curve for the logistic models.Data from 2254 infants were included. Prediction of postmenstrual age at discharge was poor. However, models that incorporated later clinical characteristics were more accurate in predicting early or late discharge (AUC: 0.76-0.83 [full models] vs 0.56-0.69 [perinatal factor models]). In simplified key-risk-factors models, the predicted probabilities for early and late discharge compared favorably with the observed rates. Furthermore, the AUC (0.75-0.77) was similar to those of the models that included the full factor set.Prediction of early or late discharge is poor if only perinatal factors are considered, but it improves substantially with knowledge of later-occurring morbidities. Predictive models that use a few key risk factors are comparable to the full models and may offer a clinically applicable strategy.

    View details for DOI 10.1542/peds.2009-0810

    View details for Web of Science ID 000273348000047

    View details for PubMedID 20008430

  • Medical Management of Extremely Low-Birth-Weight Infants in the First Week of Life: A Survey of Practices in the United States AMERICAN JOURNAL OF PERINATOLOGY Kiefer, A. S., Wickremasinghe, A. C., Johnson, J. N., Hartman, T. K., Hintz, S. R., Carey, W. A., Colby, C. E. 2009; 26 (6): 407-418


    We sought to determine the current practices of neonatologists in their management of extremely low-birth-weight (< 1000 g) infants. We directly mailed an anonymous survey to the medical directors of 809 neonatal intensive care units in the United States. More than one-third of those surveyed responded, with a substantial majority from intensive care (level III) nurseries or extracorporeal membrane oxygenation centers. Academic centers and private practice environments were both well represented. Some traditional practices have changed, such as beginning resuscitation with 40% rather than 100% oxygen. Many practices vary based on whether neonates are cared for in private versus academic centers, including initial resuscitation method, type of ventilation used, use of intraventricular hemorrhage prophylaxis, and routine antibiotic therapy. Parenteral nutrition composition and the use of inhaled nitric oxide differ based on the responding center's participation in clinical trials. The number of years in practice as a neonatologist does not affect practice decisions. Among all our findings, the prevalence of one potentially harmful practice, the continued use of dexamethasone for corticosteroid therapy, was particularly noteworthy. In conclusion, the strength of evidence does not always predict whether practices are adopted or abandoned. Further research is necessary to clarify the optimal management for this high-risk patient population.

    View details for DOI 10.1055/s-0029-1214235

    View details for Web of Science ID 000266332500002

    View details for PubMedID 19301226

  • Inhaled Nitric Oxide for Preterm Premature Rupture of Membranes, Oligohydramnios, and Pulmonary Hypoplasia AMERICAN JOURNAL OF PERINATOLOGY Chock, V. Y., Van Meurs, K. P., Hintz, S. R., Ehrenkranz, R. A., Lemons, J. A., Kendrick, D. E., Stevenson, D. K. 2009; 26 (4): 317-322


    We sought to determine if inhaled nitric oxide (iNO) administered to preterm infants with premature rupture of membranes (PPROM), oligohydramnios, and pulmonary hypoplasia improved oxygenation, survival, or other clinical outcomes. Data were analyzed from infants with suspected pulmonary hypoplasia, oligohydramnios, and PPROM enrolled in the National Institute of Child Health and Development Neonatal Research Network Preemie Inhaled Nitric Oxide (PiNO) trial, where patients were randomized to receive placebo (oxygen) or iNO at 5 to 10 ppm. Outcome variables assessed were PaO (2) response, mortality, bronchopulmonary dysplasia (BPD), and severe intraventricular hemorrhage (IVH) or periventricular leukomalacia (PVL). Twelve of 449 infants in the PiNO trial met criteria. Six infants received iNO and six received placebo. The iNO group had a mean increase in PaO (2) of 39 +/- 50 mm Hg versus a mean decrease of 11 +/- 15 mm Hg in the control group. Mortality was 33% versus 67%, BPD (2/5) 40% versus (2/2) 100%, and severe IVH or PVL (1/5) 20% versus (1/2) 50% in the iNO and control groups, respectively. None of these changes were statistically significant. Review of a limited number of cases from a large multicenter trial suggests that iNO use in the setting of PPROM, oligohydramnios, and suspected pulmonary hypoplasia improves oxygenation and may decrease the rate of BPD and death without increasing severe IVH or PVL. However, the small sample size precludes definitive conclusions. Further studies are required to determine if iNO is of benefit in this specific patient population.

    View details for DOI 10.1055/s-0028-1104743

    View details for Web of Science ID 000264506400012

    View details for PubMedID 19067285

  • Changes in Attendance at Deliveries by Pediatric Residents 2000 to 2005 AMERICAN JOURNAL OF PERINATOLOGY Lee, H. C., Rhee, C. J., Sectish, T. C., Hintz, S. R. 2009; 26 (2): 129-134


    We sought to determine if pediatric resident attendance at deliveries for newborn assessment and resuscitation had changed over the years at a training hospital. Data were abstracted from medical records of newborns discharged during the same 6-week periods for 5 consecutive academic years spanning a period before and after resident duty hour regulation changes were implemented. Names of personnel attending deliveries were noted in delivery records. The proportions of deliveries attended by any practitioner were compared by year, as well as the proportion of deliveries attended by practitioner type and training level. A total of 2666 delivery records were reviewed. The proportions of deliveries attended by any practitioner over the 5 years were similar, ranging from 43 to 49%. The proportion of deliveries attended by pediatric residents was highest at 51 to 57% from 2000 to 2002, declined to a low of 5% during 2002 to 2003, and rose to 20 to 23% during 2003 to 2005 ( P < 0.0001). The decrease in attendance by residents was compensated by an increase in attendance by hospitalists. At this training institution, pediatric resident attendance at deliveries declined substantially over recent years, likely due in part to resident duty hour regulations and increased use of hospitalists in roles previously held by residents.

    View details for DOI 10.1055/s-0028-1091395

    View details for Web of Science ID 000262934700006

    View details for PubMedID 18850515

  • Community supports after surviving extremely low-birth-weight, extremely preterm birth - Special outpatient services in early childhood ARCHIVES OF PEDIATRICS & ADOLESCENT MEDICINE Hintz, S. R., Kendrick, D. E., Vohr, B. R., Poole, W. K., Higgins, R. D. 2008; 162 (8): 748-755


    To determine special outpatient services (SOS) use, need, associated factors, and neurodevelopmental and functional outcomes among extremely preterm infants at 18 to 22 months' corrected age.Retrospective analysis.National Institute of Child Health and Human Development (NICHD) Neonatal Research Network.Infants younger than 28 weeks' gestational age who had been born weighing less than 1000 g at an NICHD Neonatal Research Network center from January 1, 1997, to December 31, 2000, and who were receiving follow-up at 18 to 22 months' corrected age.Questionnaires were administered at the 18- to 22-month follow-up visit regarding SOS use since hospital discharge and the current need for SOS (social work, visiting nurse, medical specialty, early intervention, speech and language services, occupational therapy and physical therapy, and neurodevelopmental and behavioral services).The use of and need for SOS were analyzed by gestational age. Logistic regression analysis identified factors independently associated with the use of more than 5 services and with the need for any services.Of 2315 infants, 54.7% used more than 3 SOS by 18 to 22 months, and 19.1% used 6 to 7 SOS. The need for any SOS was reported by approximately 37%. The following variables that were commonly associated with adverse neurodevelopmental outcomes were also associated with the use of more than 5 SOS: sepsis, birth weight, postnatal corticosteroid use, bronchopulmonary dysplasia, and cystic periventricular leukomalacia or grade 3 or 4 intraventricular hemorrhage. Male sex was associated with the need for any SOS. Although high SOS use was more likely among children with adverse neurodevelopmental outcomes, a reported need for SOS was common even among those with mild developmental impairment (39.7%) and mild cerebral palsy (42.2%).High SOS use is common, has identifiable neonatal risk factors, and is associated with neurodevelopmental impairment. Extremely preterm survivors have substantial need for community supports regardless of their impairment level. Efforts to improve comprehensive delivery of family-centered community-based services are urgently needed.

    View details for Web of Science ID 000258225200006

    View details for PubMedID 18678807

  • School outcomes of late preterm infants: Special needs and challenges for infants born at 32 to 36 weeks gestation JOURNAL OF PEDIATRICS Chyi, L. J., Lee, H. C., Hintz, S. R., Gould, J. B., Sutcliffe, T. L. 2008; 153 (1): 25-31


    Because limited long-term outcome data exist for infants born at 32 to 36 weeks gestation, we compared school outcomes between 32- to 33-week moderate preterm (MP), 34-36 week late preterm (LP) and full-term (FT) infants.A total of 970 preterm infants and 13 671 FT control subjects were identified from the Early Childhood Longitudinal Study-Kindergarten Cohort. Test scores, teacher evaluations, and special education enrollment from kindergarten (K) to grade 5 were compared.LP infants had lower reading scores than FT infants in K to first grade (P < .05). Adjusted risk for poor reading and math scores remained elevated in first grade (P < .05). Teacher evaluations of math skills from K to first grade and reading skills from K to fifth grade were worse for LP infants (P < .05). Adjusted odds for below average skills remained higher for math in K and for reading at all grades (P < .05). Special education participation was higher for LP infants at early grades (odds ratio, 1.4-2.1). MP infants had lower test and teacher evaluation scores than FT infants and twice the risk for special education at all grade levels.Persistent teacher concerns through grade 5 and greater special education needs among MP and LP infants suggest a need to start follow-up, anticipatory guidance, and interventions for infants born at 32 to 36 weeks gestation.

    View details for DOI 10.1016/j.jpeds.2008.01.027

    View details for Web of Science ID 000257154800010

    View details for PubMedID 18571530

  • Aluminum exposure from pediatric parenteral nutrition: Meeting the new FDA regulation JOURNAL OF PARENTERAL AND ENTERAL NUTRITION Poole, R. L., Hintz, S. R., Mackenzie, N. I., Kerner, J. A. 2008; 32 (3): 242-246


    Aluminum toxicity can cause serious central nervous system and bone toxicities. Aluminum is a contaminant of parenteral nutrition (PN) solution components. Premature neonates requiring high doses of calcium and phosphate to mineralize their bones, children with impaired renal function, and children on PN therapy for prolonged duration are at the highest risk. Effective in July 2004, the U.S. Food and Drug Administration (FDA) mandated labeling requirements for aluminum content in all PN solution components. To assess the aluminum exposure in neonatal and pediatric populations, this study aims to determine patients' daily aluminum load (mug/kg/d) delivered from PN solutions.The study included all inpatients who received PN during calendar year 2006 (13,384 PN patient days). The calculated parameters of mug/kg/d and mug/L of parentally administered aluminum were stratified according to patient age and weight. Aluminum content by product and manufacturer were tabulated.Forty-nine percent of the PN patient days were in patients weighing < 3 kg. These patients also received the largest amounts of aluminum (range, 30-60 mug/kg/d). Meeting the FDA regulation was possible only in patients weighing > 50 kg.Currently available parenteral products used to make PN solutions contain amounts of aluminum that make it impossible to meet the new FDA rule of <5 mug/kg/d of aluminum exposure. Manufacturers must identify, develop, and adopt new methods to reduce the aluminum contamination in their products. Health care professionals should calculate aluminum loads in patients and make informed decisions when choosing PN products.

    View details for DOI 10.1177/0148607108316187

    View details for Web of Science ID 000259016300003

    View details for PubMedID 18443135

  • Neuroimaging and neurodevelopmental outcomes in preterm infants SEMINARS IN PERINATOLOGY Hintz, S. R., O'Shea, M. 2008; 32 (1): 11-19


    Imaging of the preterm infant brain has advanced dramatically beyond the earliest era of transillumination. Computed tomography (CT), a crucial innovation during the early 1970s, allowed noninvasive visualization of intracerebral lesions, particularly hemorrhage. The capability to document brain injury in the preterm infant led to better clarification of links to developmental outcomes. With the development of cranial ultrasound (CUS), and more recently, magnetic resonance imaging (MRI), CT is used rarely for imaging the brain of preterm infants. Despite extensive experience with neonatal neuroimaging, significant questions still remain. Substantial controversies exist pertaining to when and how neuroimaging should be performed and how images should be interpreted.

    View details for DOI 10.1053/j.semperi.2007.12.010

    View details for Web of Science ID 000253220800003

    View details for PubMedID 18249235

  • Clinical data predict neurodevelopmental outcome better than head ultrasound in extremely low birth weight infants JOURNAL OF PEDIATRICS Broitman, E., Ambalavanan, N., Higgins, R. D., Vohr, B. R., Das, A., Bhaskar, B., Murray, K., Hintz, S. R., Carlo, W. A. 2007; 151 (5): 500-505


    To determine the relative contribution of clinical data versus head ultrasound scanning (HUS) in predicting neurodevelopmental impairment (NDI) in extremely low birth weight infants.A total of 2103 extremely low birth weight infants (<1000 g) admitted to a National Institute of Child Health and Human Development Neonatal Research Network center who underwent HUS within the first 28 days, a repeat one around 36 weeks' postmenstrual age, and neurodevelopmental assessment at 18 to 22 months corrected age were selected. Multivariate logistic regression models were developed with clinical or HUS variables. The primary outcome was the predictive abilities of the HUS performed before 28 days after birth and closer to 36 weeks postmenstrual age, either alone or in combination with "Early" and "Late" clinical variables.Models with clinical variables alone predicted NDI better than models with only HUS variables at both 28 days and 36 weeks (both P < .001), and the addition of the HUS data did not improve prediction. NDI was absent in 30% and 28% of the infants with grade IV intracranial hemorrhage or periventricular leukomalacia, respectively, but was present in 39% of the infants with a normal HUS result.Clinical models were better than HUS models in predicting neurodevelopment.

    View details for DOI 10.1016/j.jpeds.2007.04.013

    View details for Web of Science ID 000250815900013

    View details for PubMedID 17961693

  • Prenatal diagnosis of congenital diaphragmatic hernia: how should the babies be delivered? JOURNAL OF PEDIATRIC SURGERY Frenckner, B. P., Lally, P. A., Hintz, S. R., Lally, K. P. 2007; 42 (9): 1533-1538


    Congenital diaphragmatic hernia (CDH) in many patients is diagnosed in utero. In these patients, the delivery can be planned as an elective cesarean, induced vaginal, or spontaneous vaginal delivery. The optimal method has yet to be determined. The aim of this study was to compare the outcome of patients with CDH delivered by different methods.The Congenital Diaphragmatic Hernia Study Group was formed in 1995 to compile data on liveborn babies with CDH. Beginning in 2001, data concerning delivery were collected. By October 2005, delivery data were available on 1039 term and near-term infants without cardiac malformations. Five hundred forty-eight had a prenatal diagnosis and complete data on delivery (194 delivered by elective cesarean delivery, 121 by induced vaginal delivery, and 233 by spontaneous vaginal delivery). Patients delivered by a nonelective cesarean delivery were assigned to the delivery group for which they were originally planned.The overall survival among the 548 patients was 69%. It was highest in patients delivered by cesarean delivery (71%) followed by those delivered through induced vaginal delivery (70%) and spontaneous vaginal delivery (67%). The difference was not statistically significant. Fifty-three percent of all patients survived without extracorporeal membrane oxygenation (ECMO). This was significantly higher after cesarean delivery (60%) than after induced vaginal delivery (49%) or spontaneous vaginal delivery (49%) (P < .05). At 30 days of age, 45% of the patients delivered by cesarean delivery had survived and were on room air. This was slightly lower after induced vaginal delivery (37%) or after spontaneous vaginal delivery (37%), although not statistically significant.Cesarean delivery was associated with a slightly better outcome in terms of a significantly higher survival without the use of extracorporeal membrane oxygenation, although there was no significant difference in total survival. Because this study was not randomized, it is not possible to determine if the elective cesarean delivery was the cause for the better outcome or if centers favoring elective cesarean delivery by protocol are more skillful in the management of patients with CDH. Mode of delivery for term and near-term infants with CDH deserves further prospective study.

    View details for DOI 10.1016/j.jpedsurg.2007.04.016

    View details for Web of Science ID 000249746100012

    View details for PubMedID 17848244

  • Neurodevelopmental outcomes of premature infants with severe respiratory failure enrolled in a randomized controlled trial of inhaled nitric oxide JOURNAL OF PEDIATRICS Hintz, S. R., Van Meurs, K. P., Perritt, R., Poole, W. K., Das, A., Stevenson, D. K., Ehrenkranz, R. A., Lemons, J. A., Vohr, B. R., Heyne, R., Childers, D. O., Peralta-Carcelen, M., Dusick, A., Johnson, Y. R., Morris, B., Dillard, R., Vaucher, Y., Steichen, J., Adams-Chapman, I., Konduri, G., Myers, G. J., De Ungria, M., Tyson, J. E., Higgins, R. D. 2007; 151 (1): 16-22


    We hypothesized that inhaled nitric oxide (iNO) would not decrease death or neurodevelopmental impairment (NDI) in infants enrolled in the National Institute of Child Health and Human Development Preemie iNO Trial (PiNO) trial, nor improve neurodevelopmental outcomes in the follow-up group.Infants <34 weeks of age, weighing <1500 g, with severe respiratory failure were enrolled in the multicenter, randomized, controlled trial. NDI at 18 to 22 months corrected age was defined as: moderate to severe cerebral palsy (CP; Mental Developmental Index or Psychomotor score Developmental Index <70), blindness, or deafness.Of 420 patients enrolled, 109 who received iNO (52%) and 98 who received placebo (47%) died. The follow-up rate in survivors was 90%. iNO did not reduce death or NDI (78% versus 73%; relative risk [RR], 1.07; 95% CI, 0.95-1.19), or NDI or Mental Developmental Index <70 in the follow-up group. Moderate-severe CP was slightly higher with iNO (RR, 2.41; 95% CI, 1.01-5.75), as was death or CP in infants weighing <1000 g (RR, 1.22; 95% CI, 1.05-1.43).In this extremely ill cohort, iNO did not reduce death or NDI or improve neurodevelopmental outcomes. Routine iNO use in premature infants should be limited to research settings until further data are available.

    View details for DOI 10.1016/j.jpeds.2007.03.017

    View details for Web of Science ID 000247851900007

    View details for PubMedID 17586184

  • Inhaled nitric oxide in infants > 1500 g and < 34 weeks gestation with severe respiratory failure JOURNAL OF PERINATOLOGY Van Meurs, K. P., Hintz, S. R., Ehrenkranz, R. A., Lemons, J. A., Ball, M. B., Poole, W. K., Perritt, R., Das, A., Higgins, R. D., Stevenson, D. K. 2007; 27 (6): 347-352


    Inhaled nitric oxide (iNO) use in infants >1500 g, but <34 weeks gestation with severe respiratory failure will reduce the incidence of death and/or bronchopulmonary dysplasia (BPD).Infants born at <34 weeks gestation with a birth weight >1500 g with respiratory failure were randomly assigned to receive placebo or iNO.Twenty-nine infants were randomized. There were no differences in baseline characteristics, but the status at randomization showed a statistically significant difference in the use of high-frequency ventilation (P=0.03). After adjustment for oxygenation index entry strata, there was no difference in death and/or BPD (adjusted relative risk (RR) 0.80, 95% confidence interval (CI) 0.43 to 1.48; P=0.50), death (adjusted RR 1.26, 95% CI 0.47 to 3.41; P=0.65) or BPD (adjusted RR 0.40, 95% CI 0.47 to 3.41; P=0.21).Although sample size limits our ability to make definitive conclusions, this small pilot trial of iNO use in premature infants >1500 g and <34 weeks with severe respiratory failure suggests that iNO does not affect the rate of BPD and/or death.

    View details for DOI 10.1038/

    View details for Web of Science ID 000246905800005

    View details for PubMedID 17443204

  • Interobserver reliability and accuracy of cranial ultrasound scanning interpretation in premature infants JOURNAL OF PEDIATRICS Hintz, S. R., Slovis, T., Bulas, D., Van Meurs, K. P., Perritt, R., Stevenson, D. K., Poole, W. K., Das, A., Higgins, R. D. 2007; 150 (6): 592-596


    To assess interobserver reliability between 2 central readers of cranial ultrasound scanning (CUS) and accuracy of local, compared with central, interpretations.The study was a retrospective analysis of CUS data from the National Institute of Child Health and Human Development (NICHD) trial of inhaled nitric oxide for premature infants. Interobserver reliability of 2 central readers was assessed with kappa or weighted kappa. Accuracy of local, compared with central, interpretations was assessed by using sensitivity and specificity.CUS from 326 infants had both central reader and local interpretations. Central reader agreement for grade 3/4 intraventricular hemorrhage (IVH), grade 3/4 IVH or periventricular leukomalacia (PVL), grade of IVH, and degree of ventriculomegaly was very good (kappa = 0.84, 0.81, 0.79, and 0.75, respectively). Agreement was poor for lower grade IVH and for PVL alone. Local interpretations were highly accurate for grade 3/4 IVH or PVL (sensitivity, 87%-90%; specificity, 92%-93%), but sensitivity was poor-to-fair for grade 1/2 IVH (48%-68%) and PVL (20%-44%).Our findings demonstrate reliability and accuracy of highly unfavorable CUS findings, but suggest caution when interpreting mild to moderate IVH or white matter injury.

    View details for DOI 10.1016/j.jpeds.2007.02.012

    View details for Web of Science ID 000246939700011

    View details for PubMedID 17517240

  • Diagnosis of patent ductus arteriosus by a neonatologist with a compact, portable ultrasound machine JOURNAL OF PERINATOLOGY Lee, H. C., Silverman, N., Hintz, S. R. 2007; 27 (5): 291-296


    To conduct a pilot study assessing a neonatologist's accuracy in diagnosing patent ductus arteriosus (PDA) using compact, portable ultrasound after limited training.Prospective study of premature infants scheduled for echocardiography for suspected PDA. A neonatologist with limited training performed study exams before scheduled exams. Sensitivity and specificity were calculated, compared to the scheduled echocardiogram interpreted by a cardiologist.There were 24 exams. Compared to the scheduled exam, the neonatologist's exam had sensitivity 69% (95% confidence interval (CI), 41 to 89%) and specificity 88% (95% CI, 47 to 99%). When a cardiologist interpreted the study exams, the sensitivity was 87% (95% CI, 60 to 98%) and specificity 71% (95% CI, 29 to 96%).A neonatologist with limited training was able to detect PDA with moderate success. A more rigorous training process or real-time transmission with cardiologist interpretation may substantially improve accuracy. Institutions with experienced technicians and on-site pediatric cardiologists may not gain from intensive training of neonatologists, but hospitals where diagnosis and treatment of PDA would be delayed may benefit from such processes.

    View details for DOI 10.1038/

    View details for Web of Science ID 000246105400008

    View details for PubMedID 17363908

  • Hypothermia for the treatment of neonatal ischemic encephalopathy: Is the genie out of the bottle? AMERICAN JOURNAL OF PERINATOLOGY Lang, T. R., Hartman, T. K., Hintz, S. R., Colby, C. E. 2007; 24 (1): 27-31


    Evidence suggests that hypothermia for hypoxic ischemic encephalopathy in the term neonate may decrease the risk of death or neurodevelopmental impairment. The objective of this study was to determine how hypothermia has been incorporated into practice. An anonymous survey was sent to medical directors of United States neonatal intensive care units (NICUs) in October 2005. We received completed surveys from 441 (54.5%) of 809 of NICUs. Only 6.4% of respondents used hypothermia. The most common method was total body cooling (64.3%) compared with head cooling (25%) or both (10.7%). At centers that did not offer hypothermia, 29% transferred infants to an institution that did. Centers that offered hypothermia were more likely at academic institutions (76.9%) compared with private practices (11.5%; p < 0.001). Hypothermia was more likely offered at institutions that offered extracorporeal membrane oxygenation (ECMO; 57%) than centers where ECMO was not offered (43%; p < 0.001). There has not been widespread use of hypothermia. There are a variety of protocols used. As results of further outcome studies become available, educational efforts and national practice guidelines will be essential.

    View details for DOI 10.1055/s-2006-958157

    View details for Web of Science ID 000245040700006

    View details for PubMedID 17195147

  • Gender differences in neurodevelopmental outcomes among extremely preterm, extremely-low-birthweight infants ACTA PAEDIATRICA Hintz, S. R., Kendrick, D. E., Vohr, B. R., Poole, W. K., Higgins, R. D. 2006; 95 (10): 1239-1248


    To determine whether gender-specific responses to perinatal and neonatal events and exposures explain the male disadvantage in early childhood outcomes.Infants were in the National Institute of Child Health and Human Development (NICHD) Neonatal Research Network, born 1/1/1997-12/31/2000, <28 wk, with neurodevelopmental follow-up at 18-22 mo corrected age. We evaluated and compared univariate and multivariate associations of risk factors with neurodevelopmental outcomes for girls and boys. Neurodevelopmental impairment (NDI) was one or more of the following: moderate--severe cerebral palsy (CP), Bayley Mental (MDI) or Psychomotor (PDI) Development Indices <70, deafness or blindness.Boys (n=1216) were more likely than girls (n=1337) to have adverse outcomes (moderate--severe CP: 10.7% vs 7.3%; MDI < 70: 41.9% vs 27.1%; NDI: 48.1% vs 34.1%). Major risk factors were also more common in boys. Independent multivariate associations of risk factors with outcome differed by gender, but not consistently in favor of girls. In multivariate models including both girls and boys, male gender remained an independent risk factor for MDI < 70 (2.0, 95% CI 1.6-2.5) and NDI (1.8, 95% CI 1.5-2.2).Perinatal, neonatal and early childhood factors confer similar incremental risk or protection to boys and girls, but boys appear to have inherently greater baseline risk. Unmeasured biological variables likely contribute to the preterm male neurodevelopmental outcome disadvantage.

    View details for DOI 10.1080/08035250600599727

    View details for Web of Science ID 000240562000016

    View details for PubMedID 16982497

  • The use of inhaled nitric oxide in the premature infant with respiratory distress syndrome. Minerva pediatrica Van Meurs, K., Hintz, S., Rhine, W., Benitz, W. 2006; 58 (5): 403-422


    The identification of the biologic properties of nitric oxide (NO) is one of the key scientific discoveries of the century, but its potential for treating human disease is yet to be fully realized. NO has a basic role in regulating vascular tone of the pulmonary circulation, and recent animal models have suggested a more wide reaching influence on perinatal lung development. In animal models, NO has effects on lung growth, angiogenesis, airway smooth muscle proliferation, vascular remodeling, surfactant function, inflammation, and pulmonary mechanics. However, despite extensive basic science investigation and completion of several large clinical trials, the role of NO in the treatment of the premature infant with respiratory distress syndrome remains unclear. One must conclude that the interaction of lung immaturity, ventilator and oxygen-induced lung injury, and NO biology in the premature newborn is incompletely understood. Clinical trial results of inhaled NO therapy in the premature infant are accumulating, but the results do not suggest a clear-cut advantage for the population at greatest risk for death and disability. Whether trial design, dose, duration of therapy, or other factors are responsible has not been determined. Further research is needed to answer these questions and more clearly define the population of premature infants who may derive benefit from this new therapy.

    View details for PubMedID 17008853

  • Changes in neurodevelopmental outcomes at 18 to 22 months' corrected age among infants of less than 25 weeks' gestational age born in 1993-1999 PEDIATRICS Hintz, S. R., Kendrick, D. E., Vohr, B. R., Poole, W. K., Higgins, R. D. 2005; 115 (6): 1645-1651


    Increased survival rates for extremely preterm, extremely low birth weight infants during the postsurfactant era have been reported, but data on changes in neurosensory and developmental impairments are sparse.To compare neuromotor and neurodevelopmental outcomes at 18 to 22 months' corrected age for infants of <25 weeks' estimated gestational age (EGA) who were born in the 1990s.This was a multicenter, retrospective, comparative analysis of infants of <25 weeks' EGA, with birth weights of 501 to 1000 g, born between January 1993 and June 1996 (epoch I) or between July 1996 and December 1999 (epoch II), in the National Institute of Child Health and Human Development Neonatal Research Network. Neurodevelopmental assessments were performed at 18 to 22 months' corrected age. Logistic-regression models were constructed to evaluate the independent risk of cerebral palsy, Mental Development Index of <70, Psychomotor Development Index of <70, and neurodevelopmental impairment.A total of 366 patients in epoch I and 473 patients in epoch II were evaluated. Prenatal steroid use, cesarean section, surfactant treatment, bronchopulmonary dysplasia, and severe retinopathy of prematurity were more likely in epoch II, whereas Apgar scores of <5 at 5 minutes, patent ductus arteriosus, and severe intraventricular hemorrhage were more likely in epoch I. The prevalences of cerebral palsy, Psychomotor Development Index of <70, and neurodevelopmental impairment were similar between epochs. The prevalences of Mental Development Index of <70 were 40% for epoch I and 47% for epoch II. Regression analysis revealed that epoch II was an independent risk factor for Mental Developmental Index of <70 (epoch I versus II: odds ratio: 0.63; 95% confidence interval: 0.45-0.87) but not for other outcomes.Early childhood neurodevelopmental outcomes among infants of <25 weeks' EGA are not improving in the postsurfactant era, despite more aggressive perinatal and neonatal treatment. Later childhood follow-up assessment is needed to delineate trends in severe cognitive impairment in this extremely high-risk group.

    View details for DOI 10.1542/peds.2004-2215

    View details for Web of Science ID 000229504800025

    View details for PubMedID 15930228

  • Changes in mortality and morbidities among infants born at less than 25 weeks during the post-surfactant era ARCHIVES OF DISEASE IN CHILDHOOD Hintz, S. R., Poole, W. K., Wright, L. L., Fanaroff, A. A., Kendrick, D. E., Laptook, A. R., Goldberg, R., Duara, S., Stoll, B. J., Oh, W. 2005; 90 (2): F128-F133


    To compare mortality and death or major morbidity (DOMM) among infants <25 weeks estimated gestational age (EGA) born during two post-surfactant era time periods.Comparative cohort study of very low birthweight (501-1500 g) infants <25 weeks EGA in the NICHD Neonatal Research Network born during two post-surfactant era time periods (group I, 1991-1994, n=1408; group II, 1995-1998, n=1348). Perinatal and neonatal factors were compared, and group related mortality and DOMM risk were evaluated.Mortality was higher for group I (63.1% v 56.7%; p=0.0006). Antenatal steroids (ANS) and antenatal antibiotics (AABX), surfactant (p<0.0001), and bronchopulmonary dysplasia (p=0.0008) were more prevalent in group II. In a regression model that controlled for basic and delivery factors only, mortality risk was greater for group I than for group II (odds ratio (OR) 1.4, 95% confidence interval (CI) 1.2 to 1.7); the addition of AABX and surfactant, or ANS (OR 0.97, 95% CI 0.79 to 1.2) to the model appeared to account for this difference. There was no difference in DOMM (86.8% v 88.4%; p=0.2), but risk was lower for group I in regression models that included ANS (OR 0.70, 95% CI 0.52 to 0.94).Survival to discharge was more likely during the more recent period because of group differences in ANS, AABX, and surfactant. However, this treatment shift may reflect an overall more aggressive management approach. More consistent application of treatment has led to improving survival of <25 week EGA infants during the post-surfactant era, but possibly at the cost of greater risk of major in-hospital morbidities.

    View details for DOI 10.1136/adc.2003.046268

    View details for Web of Science ID 000227543700009

    View details for PubMedID 15724036

  • Changes in mortality and morbidities among infants born at less than 25 weeks during the post-surfactant era ARCHIVES OF DISEASE IN CHILDHOOD-FETAL AND NEONATAL EDITION Hintz, S. R., Poole, W. K., Wright, L. L., Fanaroff, A. A., Kendrick, D. E., Laptook, A. R., Goldberg, R., Duara, S., Stoll, B. J., Oh, W. 2005; 90 (2): 128-133
  • Neurodevelopmental and growth outcomes of extremely low birth weight infants after necrotizing enterocolitis PEDIATRICS Hintz, S. R., Kendrick, D. E., Stoll, B. J., Vohr, B. R., Fanaroff, A. A., Donovan, E. F., Poole, W. K., Blakely, M. L., Wright, L., Higgins, R. 2005; 115 (3): 696-703


    Necrotizing enterocolitis (NEC) is a significant complication for the premature infant. However, subsequent neurodevelopmental and growth outcomes of extremely low birth weight (ELBW) infants with NEC have not been well described. We hypothesized that ELBW infants with surgically managed (SurgNEC) are at greater risk for poor neurodevelopmental and growth outcomes than infants with medically managed NEC (MedNEC) compared with infants without a history of NEC (NoNEC). The objective of this study was to compare growth, neurologic, and cognitive outcomes among ELBW survivors of SurgNEC and MedNEC with NoNEC at 18 to 22 months' corrected age.Multicenter, retrospective analysis was conducted of infants who were born between January 1, 1995, and December 31, 1998, and had a birth weight <1000 g in the National Institute of Child Health and Human Development Neonatal Research Network Registry. Neurodevelopment and growth were assessed at 18 to 22 months' postmenstrual age. chi2, t test, and logistic regression analyses were used.A total of 2948 infants were evaluated at 18 to 22 months, 124 of whom were SurgNEC and 121 of whom were MedNEC. Compared with NoNEC, both SurgNEC and MedNEC infants were of lower birth weight and had a greater incidence of late sepsis; SurgNEC but not MedNEC infants were more likely to have received a diagnosis of cystic periventricular leukomalacia and bronchopulmonary dysplasia and been treated with postnatal steroids. Weight, length, and head circumference <10 percentile at 18 to 22 months were significantly more likely among SurgNEC but not MedNEC compared with NoNEC infants. After correction for anthropometric measures at birth and adjusted age at follow-up, all growth parameters at 18 to 22 months for SurgNEC but not MedNEC infants were significantly less than for NoNEC infants. SurgNEC but not MedNEC was a significant independent risk factor for Mental Developmental Index <70 (odds ratio [OR]: 1.61; 95% confidence interval [CI]: 1.05-2.50), Psychomotor Developmental Index <70 (OR: 1.95; 95% CI: 1.25-3.04), and neurodevelopmental impairment (OR: 1.78; 95% CI: 1.17-2.73) compared with NoNEC.Among ELBW infants, SurgNEC is associated with significant growth delay and adverse neurodevelopmental outcomes at 18 to 22 months' corrected age compared with NoNEC. MedNEC does not seem to confer additional risk. SurgNEC is likely to be associated with greater severity of disease.

    View details for DOI 10.1542/peds.2004-0569

    View details for Web of Science ID 000227596900029

    View details for PubMedID 15741374

  • Utilization and outcomes of neonatal cardiac extracorporeal life support: 1996-2000. Pediatric critical care medicine Hintz, S. R., Benitz, W. E., Colby, C. E., Sheehan, A. M., Rycus, P., Van Meurs, K. P. 2005; 6 (1): 33-38


    Extracorporeal life support for neonatal respiratory failure has decreased, but utilization and outcome of cardiac extracorporeal life support are not well characterized. Among neonates born 1996-2000, our objects were to evaluate changes in utilization and outcome of cardiac extracorporeal life support and characterize correlates of survival.Retrospective analysis of Extracorporeal Life Support Organization Registry data.Intensive care units participating in the ELSO registry.Patients placed on extracorporeal life support for center-specified "cardiac support" at 15 days was associated with improved survival among hypoplastic left heart syndrome patients (p = .03), and survivors had fewer mean extracorporeal life support hours (89.3 +/- 52.3 vs. 147.5 +/- 129.7, p = .015). Logistic regression showed that only greater number of hours on extracorporeal life support was independently associated with nonsurvival.Neonatal cardiac extracorporeal life support use increased substantially from 1996 to 2000, with survival to discharge or transfer in more than one third of patients. Hypoplastic left heart syndrome was not associated with nonsurvival. Fewer hours on extracorporeal life support, diagnoses of persistent pulmonary hypertension of the neonate and transposition of the great arteries, and extracorporeal life support at <3 days were associated with survival.

    View details for PubMedID 15636656

  • Neurodevelopmental and growth impairment among extremely low-birth-weight infants with neonatal infection JAMA-JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION Stoll, B. J., Hansen, N. I., Adams-Chapman, I., Fanaroff, A. A., Hintz, S. R., Vohr, B., Higgins, R. D. 2004; 292 (19): 2357-2365


    Neonatal infections are frequent complications of extremely low-birth-weight (ELBW) infants receiving intensive care.To determine if neonatal infections in ELBW infants are associated with increased risks of adverse neurodevelopmental and growth sequelae in early childhood.Infants weighing 401 to 1000 g at birth (born in 1993-2001) were enrolled in a prospectively collected very low-birth-weight registry at academic medical centers participating in the National Institute of Child Health and Human Development Neonatal Research Network. Neurodevelopmental and growth outcomes were assessed at a comprehensive follow-up visit at 18 to 22 months of corrected gestational age and compared by infection group. Eighty percent of survivors completed the follow-up visit and 6093 infants were studied. Registry data were used to classify infants by type of infection: uninfected (n = 2161), clinical infection alone (n = 1538), sepsis (n = 1922), sepsis and necrotizing enterocolitis (n = 279), or meningitis with or without sepsis (n = 193).Cognitive and neuromotor development, neurologic status, vision and hearing, and growth (weight, length, and head circumference) were assessed at follow-up.The majority of ELBW survivors (65%) had at least 1 infection during their hospitalization after birth. Compared with uninfected infants, those in each of the 4 infection groups were significantly more likely to have adverse neurodevelopmental outcomes at follow-up, including cerebral palsy (range of significant odds ratios [ORs], 1.4-1.7), low Bayley Scales of Infant Development II scores on the mental development index (ORs, 1.3-1.6) and psychomotor development index (ORs, 1.5-2.4), and vision impairment (ORs, 1.3-2.2). Infection in the neonatal period was also associated with impaired head growth, a known predictor of poor neurodevelopmental outcome.This large cohort study suggests that neonatal infections among ELBW infants are associated with poor neurodevelopmental and growth outcomes in early childhood. Additional studies are needed to elucidate the pathogenesis of brain injury in infants with infection so that novel interventions to improve these outcomes can be explored.

    View details for Web of Science ID 000225070100024

    View details for PubMedID 15547163

  • Surfactant replacement therapy on ECMO does not improve outcome in neonates with congenital diaphragmatic hernia JOURNAL OF PEDIATRIC SURGERY Colby, C. E. 2004; 39 (11): 1632-1637


    Respiratory failure in neonates with congenital diaphragmatic hernia (CDH) may in part be caused by a primary or secondary surfactant deficiency. Knowledge of the optimal approach to surfactant replacement in neonates with CDH and respiratory failure is limited. The aim of this study was to determine if surfactant replacement on extracorporeal membrane oxygenation (ECMO) results in improved outcomes in neonates > or =35 weeks' gestation with unrepaired CDH.Using the CDH Study Group Registry, the authors identified 448 neonates with CDH who were > or =35 weeks' gestation, had no major anomalies, were treated with ECMO within the first 7 days of life, and underwent repair on or after ECMO therapy. Patients in 2 groups were compared: group 1 (- Surf, n = 334) consisted of patients who received no surfactant and group 2 (+ Surf, n = 114) consisted of patients who received at least 1 dose of surfactant while on ECMO. An analysis of all patients in both groups was performed. Additionally, subgroup analyses stratified by gestational age were performed for patients 351/7 to 366/7 weeks' gestation and for patients > or =37 weeks' gestation. Primary end-points for the study were survival and length of ECMO run. Secondary end-points were length of intubation, need for supplemental oxygen at 30 days of life, and at discharge to home. Demographic, clinical, and outcome variables were examined using Fisher's Exact tests for categorical variables and using unpaired t tests for continuous variables. Odds ratios were calculated for categorical end-point variables.Demographic and clinical variables were similar between groups. Analyses of aggregate data showed no significant differences between groups in length of ECMO run, survival, number of days intubated, and percent of patients requiring supplemental oxygen at 30 days or discharge. Subgroup stratification by gestational age did not show significant differences between groups in any of the outcome variables.The data from this study suggest that surfactant replacement on ECMO for neonates with congenital diaphragmatic hernia does not provide significant benefit in the infant's clinical course with respect to survival, length of ECMO course, length of intubation, or subsequent need for supplemental oxygen.

    View details for DOI 10.1016/j.pedsurg.2004.07.005

    View details for Web of Science ID 000225445100005

    View details for PubMedID 15547824

  • Neonatal brain magnetic resonance imaging before discharge is better than serial cranial ultrasound in predicting cerebral palsy in very low birth weight preterm infants PEDIATRICS Mirmiran, M., Barnes, P. D., Keller, K., Constantinou, J. C., Fleisher, B. E., Hintz, S. R., Ariagno, R. L. 2004; 114 (4): 992-998


    To compare the value of serial cranial ultrasound (US) with a single magnetic resonance imaging (MRI) before discharge in very low birth weight preterm infants to predict cerebral palsy (CP).Infants who weighed <1250 g at birth and were <30 weeks' gestational age underwent conventional brain MRI at near term (36-40 weeks' postmenstrual age) using 1.5 Tesla MRI scanner. Sagittal and axial T1 and T2 fluid attenuated inversion recovery and gradient recalled echo images were obtained. Cranial US was also obtained at least twice during the first 2 weeks of life. MRI and US images were interpreted by 2 independent radiologists, who were masked to clinical outcome, and scored as follows: category 1, no abnormality; category 2, subependymal hemorrhage or mineralization; category 3, moderate to severe ventriculomegaly; category 4, focal parenchymal abnormality with or without ventriculomegaly. For the purpose of this study, 1 and 2 were categorized as "normal," and 3 and 4 were categorized as "abnormal." The infants were assessed at a mean age of 20 and 31 months using the Amiel-Tison standardized neurodevelopmental examination.The sensitivity and specificity of MRI for predicting CP were 71% and 91% at 20 month and 86% and 89% at 31 months, respectively. The sensitivity and specificity of US for predicting CP were 29% and 86% at 20 months and 43% and 82% at 31 months.As a predictor of outcome for CP, MRI at near-term in very low birth weight preterm neonates is superior to US. However, both US and MRI demonstrate high specificity.

    View details for DOI 10.1542/peds.2003-0772-L

    View details for Web of Science ID 000224242200034

    View details for PubMedID 15466096

  • Low yield of ancillary diagnostic studies in neonates infected with Candida. Journal of perinatology Colby, C. E., Drohan, L., Benitz, W., Hintz, S. R. 2004; 24 (4): 241-246


    Fungal infection can be a significant complication for the critically ill neonate. However, the usefulness of extensive radiologic and ophthalmologic investigations in this population has not been thoroughly elucidated.To report the incidence of organ fungal involvement diagnosed by ancillary testing (echocardiogram, ophthalmologic examination, brain imaging, and renal ultrasound (RUS)) among neonatal intensive care unit (NICU) patients with Candida infection.This was a single center review of all NICU patients with Candida-positive cultures of blood, urine, peritoneal fluid, endotracheal tube aspirate, or cerebrospinal fluid from January 1, 1997 to June 1 2002. Data regarding the number of positive cultures, species isolated, and presence of specific risk factors and clinical symptoms were recorded for each case, as well as occurrence, timing and results of ancillary testing.In all, 66 patients had at least one positive culture for Candida. The majority (71%) were <1500 g at birth, and mean gestational age was 29.5+/-5.6 weeks. Echocardiograms were obtained in 54/66 (82%), and ophthalmology examinations were obtained in 36/66 (55%); none of these was consistent with fungal involvement. Brain imaging was performed in 50/66 (76%), only one of which was positive, in a patient with 16 positive blood cultures for Candida albicans. RUS were performed in 58/66 (88%) of patients, with concerning findings for fungal involvement in seven of the studies. RUS findings alone did not appear to consistently influence the length of therapy.Ancillary evaluations to investigate for fungal dissemination were undertaken frequently, but were of overall low yield. Although ancillary testing may be of limited additional value in centers with a low threshold for suspecting fungal infections and an aggressive approach to therapy, potentially important findings, which could impact management, may occur.

    View details for PubMedID 15014535

  • Pulmonary glial heterotopia in a monoamniotic twin PEDIATRIC PULMONOLOGY Morgan, T., Anderson, J., Jorden, M., Keller, K., Robinson, T., Hintz, S. 2003; 36 (2): 162-166


    Brain heterotopia in the lungs is rare, but when it occurs in an otherwise healthy newborn, it presents a difficult diagnostic problem and uncertain pathophysiology. We report on a 2-week-old premature infant who presented with respiratory distress and widespread cystic lung changes identified by chest imaging studies. Autopsy demonstrated that the cyst walls were composed of well-differentiated neuroglial tissue, which was confirmed by immunohistochemistry. The cysts were partially lined by bronchial epithelium and contained keratinous debris. For the first time, we demonstrate that the debris stain for human chorionic gonadotropin, compatible with aspirated amnion. There were no other congenital abnormalities. Her monoamniotic twin was anencephalic and died at birth. Although the etiology of glial heterotopia in the lungs is unknown, the majority of cases are associated with anencephalic newborns. Some authors postulated that this heterotopia may therefore be a consequence of fetal aspiration of brain tissue. Other possibilities include glial predominant teratomas, hamartomatous malformations, and abnormal neural crest migration. Our review of the 21 cases reported over the past century suggests that in utero aspiration of glial cells, or abnormal neural crest migration, are the most likely explanations for this rare and fatal disease.

    View details for DOI 10.1002/ppul.10292

    View details for Web of Science ID 000184621100011

    View details for PubMedID 12833496

  • The jaundiced newborn. Understanding and managing transitional hyperbilirubinemia. Minerva pediatrica Stevenson, D. K., Wong, R. J., Hintz, S. R., Vreman, H. J. 2002; 54 (5): 373-382


    Neonatal jaundice is one of the most common conditions diagnosed by the pediatrician. This normally benign transitional phenomenon is a dynamic balance between the production and elimination of bilirubin. These processes can be exacerbated by a number of pathophysiologic conditions, which cause either an increase in bilirubin production rates, such as hemolysis, or a decrease in bilirubin elimination rates, such as bilirubin conjugation defects. The most dangerous circumstance for an infant is the combination of increased bilirubin production with impaired elimination. These infants are at considerable risk for developing excessive and potentially dangerous hyperbilirubinemia and subsequent kernicterus. Therefore, the importance of early recognition of the imbalance is paramount. In this review, we will discuss the various risk factors associated with hyperbilirubinemia and describe strategies for the diagnosis and management of transitional hyperbilirubinemia.

    View details for PubMedID 12244276

  • Early neonatal diagnosis of long-chain 3-hydroxyacyl coenzyme A dehydrogenase and mitochondrial trifunctional protein deficiencies MOLECULAR GENETICS AND METABOLISM Hintz, S. R., Matern, D., Strauss, A., Bennett, M. J., Hoyme, H. E., Schelley, S., Kobori, J., Colby, C., Lehman, N. L., Enns, G. M. 2002; 75 (2): 120-127


    Tandem mass spectrometry (MS/MS) has been introduced in several newborn screening programs for the detection of a large number of inborn errors of metabolism, including fatty acid oxidation disorders (FAOD). Early identification and treatment of FAOD have the potential to improve outcome and may be life-saving in some cases; an estimated 5% of sudden infant deaths are attributable to undiagnosed disorders of fatty acid oxidation. We report very early neonatal presentations of long-chain 3-hydroxyacyl-CoA dehydrogenase (LCHAD) and mitochondrial trifunctional protein (TFP) deficiencies confirmed by molecular analysis. Both patients had cardiorespiratory collapse and hypoglycemia, without a history of maternal pregnancy complications. Retrospective MS/MS analysis of the original newborn screening blood spots revealed characteristic acylcarnitine profiles. These cases are among the earliest reported presentations of LCHAD and TFP deficiencies and further illustrate the potential of MS/MS as a valuable tool for newborn screening of FAOD. However, timely analysis and reporting of results to clinicians are essential, because these disorders can manifest in the first few days of life.

    View details for DOI 10.1006/mgme.2001.3282

    View details for Web of Science ID 000174355300003

    View details for PubMedID 11855930

  • Understanding newborn jaundice. Journal of perinatology Stevenson, D. K., Dennery, P. A., Hintz, S. R. 2001; 21: S21-4

    View details for PubMedID 11803411

  • Just when you thought it was safe... PEDIATRIC RESEARCH Hintz, S. R., Stevenson, D. K. 2001; 50 (6): 676-677

    View details for Web of Science ID 000172398500004

    View details for PubMedID 11726720

  • Limb/pelvis hypoplasia/aplasia with skull defect (Schinzel phocomelia): Distinctive features and prenatal detection AMERICAN JOURNAL OF MEDICAL GENETICS Olney, R. S., Hoyme, H. E., Roche, F., Ferguson, K., Hintz, S., Madan, A. 2001; 103 (4): 295-301


    Schinzel phocomelia syndrome is characterized by limb/pelvis hypoplasia/aplasia: specifically, intercalary limb deficiencies and absent or hypoplastic pelvic bones. The phenotype is similar to that described in a related multiple malformation syndrome known as Al-Awadi/Raas-Rothschild syndrome. The additional important feature of large parietooccipital skull defects without meningocele, encephalocele, or other brain malformation has thus far been reported only in children with Schinzel phocomelia syndrome. We recently evaluated a boy affected with Schinzel phocomelia born to nonconsanguineous healthy parents of Mexican origin. A third-trimester fetal ultrasound scan showed severe limb deficiencies and an absent pelvis. The infant died shortly after birth. Dysmorphology examination, radiographs, and autopsy revealed quadrilateral intercalary limb deficiencies with preaxial toe polydactyly; an absent pelvis and a 7 x 3-cm skull defect; and extraskeletal anomalies including microtia, telecanthus, micropenis with cryptorchidism, renal cysts, stenosis of the colon, and a cleft alveolar ridge. A normal 46,XY karyotype was demonstrated, and autosomal recessive inheritance was presumed on the basis of previously reported families. This case report emphasizes the importance of recognizing severe pelvic and skull deficiencies (either post- or prenatally) in differentiating infants with Schinzel phocomelia from other multiple malformation syndromes that feature intercalary limb defects, including thalidomide embryopathy and Roberts-SC phocomelia.

    View details for Web of Science ID 000171752600006

    View details for PubMedID 11746009

  • Serum bilirubin levels at 72 hours by selected characteristics in breastfed and formula-fed term infants delivered by cesarean section ACTA PAEDIATRICA Hintz, S. R., Gaylord, T. D., Oh, W., Fanaroff, A. A., Mele, L., Stevenson, D. K. 2001; 90 (7): 776-781


    The present multicenter study analysed the relative impact of maternal and infant factors on serum bilirubin levels at 72 +/- 12 h in exclusively breastfed vs formula-fed term infants. End-tidal carbon monoxide levels corrected for ambient air (ETCOc), an index of bilirubin production, were measured in exclusively breastfed (B = 66) or formula-fed (F = 210) term infants at 2-8 h of age. Inclusion criteria included cesarean section to ensure a 3 d hospitalization, birthweight > or = 2,500 g, gestational age >37 wk and absence of any illness. The ETCOc for B infants and F infants did not differ significantly (1.3 +/- 0.7 ppm vs 1.3 +/- 0.8 ppm). The serum bilirubin level at 72 +/- 12 h was significantly higher in B infants than in F infants (8.5 +/- 3.4mg dl(-1) vs 6.7 +/- 3.4mg dl(-1) p < 0.001), as was the percentage weight loss from birthweight. Serum bilirubin levels were significantly higher in infants who were male, who did not have meconium-stained amniotic fluid, and in those whose mothers were insulin-dependent diabetics or hypertensive. There was no difference between groups in the need for phototherapy or exchange transfusion.Although higher bilirubin levels were observed in group B at 72 +/- 12 h compared with group F, this finding was not of clinical or therapeutic consequence in this study. The lack of difference in ETCOc between the groups may be a factor of the timing of ETCOc measurement in this study, or may suggest that early increased bilirubin production is not a significant contributor to jaundice observed in exclusively breastfed infants. Key words: bilirubin, breastfeeding, jaundice

    View details for Web of Science ID 000170367700013

    View details for PubMedID 11519981

  • Bedside functional imaging of the premature infant brain during passive motor activation JOURNAL OF PERINATAL MEDICINE Hintz, S. R., Benaron, D. A., Siegel, A. M., Zourabian, A., Stevenson, D. K., Boas, D. A. 2001; 29 (4): 335-343


    Changes in regional brain blood flow and hemoglobin oxygen saturation occur in the human cortex in response to neural activation. Traditional functional radiologic methods cannot provide continuous, portable measurements. Imaging methods, which use near-infrared light allow for non-invasive measurements by taking advantage of the fact that hemoglobin is a strong absorber at these wavelengths.To test the feasibility of a new optical functional imaging system in premature infants, and to obtain preliminary brain imaging of passive motor activation in this population.A new optical imaging system, the Diffuse Optical Tomography System (DOTS), was used to provide real-time, bedside assessments. Custom-made soft flexible fiberoptic probes were placed on two extremely ill, mechanically ventilated 24 week premature infants, and three healthier 32 week premature infants. Passive motor stimulation protocols were used during imaging.Specific movement of the arm resulted in reproducible focal, contralateral changes in cerebral absorption. The data suggest an overall increase in blood volume to the imaged area, as well as an increase in deoxyhemoglobin concentration. These findings in premature infants differ from those expected in adults.In the intensive care setting, continuous non-invasive optical functional imaging could be critically important and, with further study, may provide a bedside monitoring tool for prospectively identifying patients at high risk for brain injury.

    View details for Web of Science ID 000170867600010

    View details for PubMedID 11565203

  • Decreased use of neonatal extracorporeal membrane oxygenation (ECMO): How new treatment modalities have affected ECMO utilization PEDIATRICS Hintz, S. R., Suttner, D. M., Sheehan, A. M., Rhine, W. D., Van Meurs, K. P. 2000; 106 (6): 1339-1343


    Over the last decade, several new therapies, including high-frequency oscillatory ventilation (HFOV), exogenous surfactant therapy, and inhaled nitric oxide (iNO), have become available for the treatment of neonatal hypoxemic respiratory failure. The purpose of this retrospective study was to ascertain to what extent these modalities have impacted the use of neonatal extracorporeal membrane oxygenation (ECMO) at our institution.Patients from 2 time periods were evaluated: May 1, 1993 to November 1, 1994 (group 1) and May 1, 1996 to November 1, 1997 (group 2). During the first time period (group 1), HFOV was not consistently used; beractant (Survanta) use for meconium aspiration syndrome (MAS), persistent pulmonary hypertension of the newborn (PPHN), and pneumonia was under investigation; and iNO was not yet available. During the second time period (group 2), HFOV and beractant treatment were considered to be standard therapies, and iNO was available to patients with oxygenation index (OI) >/=25 x 2 at least 30 minutes apart, or on compassionate use basis. Patients were included in the data collection if they met the following entry criteria: 1) OI >15 x 1 within the first 72 hours of admission; 2) EGA >/=35 weeks; 3) diagnosis of MAS, PPHN or sepsis/pneumonia; 4) <5 days of age on admission; and 5) no congenital heart disease, diaphragmatic hernia, or lethal congenital anomaly.Of the 49 patient in group 1, 21 (42.8%) required ECMO therapy. Of these ECMO patients, 14 (66.6%) had received diagnoses of MAS or PPHN. Only 3 of the patients that went on to ECMO received beractant before the initiation of bypass (14.3%). All ECMO patients in group 1 would have met criteria for iNO had it been available. Of all patients in group 1, 18 (36.7%) were treated with HFOV, and 13 (26.5%) received beractant. Of the 47 patients in group 2, only 13 (27.7%) required ECMO therapy (compared with group 1). Of these ECMO patients, only 5 (38.5%) had diagnoses of MAS or PPHN, with the majority of patients (61.5%) requiring ECMO for sepsis/pneumonia, with significant cardiovascular compromise. Only 5 of these ECMO patients, all outborn, did not receive iNO before cannulation because of the severity of their clinical status on admission. Of all patients in group 2, 41 (87.2%) were treated with HFOV (compared with group 1), 42 (89.3%) received beractant (compared with group 1), and 18 (44.7%) received iNO.The results indicate that ECMO was used less frequently when HFOV, beractant and iNO was more commonly used. The differences in treatment modalities used and subsequent use of ECMO were statistically significant. We speculate that, in this patient population, the diagnostic composition of neonatal ECMO patients has changed over time.

    View details for Web of Science ID 000165914800020

    View details for PubMedID 11099586

  • Secondary infection presenting as recurrent pulmonary hypertension. Journal of perinatology Hintz, S. R., Benitz, W. E., Halamek, L. P., Van Meurs, K. P., Rhine, W. D. 2000; 20 (4): 262-264


    Primary infection in the neonate, especially group B streptococcal infection, has long been recognized as a cause of persistent pulmonary hypertension of the newborn (PPHN), sometimes requiring treatment with inhaled nitric oxide (iNO) and extracorporeal membrane oxygenation (ECMO). However, secondary nosocomial infections in the neonatal period have not been widely reported as a cause of severe recurrent pulmonary hypertension (PHTN). We now present two cases of secondary infection in the neonate leading to significant PHTN. In both cases, the infants presented with PPHN soon after birth, requiring transfer to a level 3 neonatal intensive care unit and treatment with high-frequency oscillatory ventilation and iNO. After successful resolution of the initial PPHN, including extubation to nasal cannula, both infants developed signs of severe recurrent PHTN, leading to reintubation, high-frequency oscillatory ventilation and iNO therapy, and consideration of ECMO. In both cases, blood cultures taken at the time of recurrence of PHTN returned positive, one for Staphylococcus epidermidis, the other for methicillin-resistant Staphylococcus aureus. These unusual cases present the possibility of severe recurrent PHTN requiring iNO or ECMO in the setting of secondary infection. We speculate that these infants, although extubated after their first episodes of PHTN, were at risk for recurrence of PHTN due to continued pulmonary vascular reactivity.

    View details for PubMedID 10879342

  • Noninvasive functional imaging of human brain using light JOURNAL OF CEREBRAL BLOOD FLOW AND METABOLISM Benaron, D. A., Hintz, S. R., Villringer, A., Boas, D., Kleinschmidt, A., Frahm, J., Hirth, C., Obrig, H., van Houten, J. C., Kermit, E. L., Cheong, W. F., Stevenson, D. K. 2000; 20 (3): 469-477


    Analysis of photon transit time for low-power light passing into the head, and through both skull and brain, of human subjects allowed for tomographic imaging of cerebral hemoglobin oxygenation based on photon diffusion theory. In healthy adults, imaging of changes in hemoglobin saturation during hand movement revealed focal, contralateral increases in motor cortex oxygenation with spatial agreement to activation maps determined by functional magnetic resonance imaging; in ill neonates, imaging of hemoglobin saturation revealed focal regions of low oxygenation after acute stroke, with spatial overlap to injury location determined by computed tomography scan. Because such slow optical changes occur over seconds and co-localize with magnetic resonance imaging vascular signals whereas fast activation-related optical changes occur over milliseconds and co-localize with EEG electrical signals, optical methods offer a single modality for exploring the spatio-temporal relationship between electrical and vascular responses in the brain in vivo, as well as for mapping cortical activation and oxygenation at the bedside in real-time for clinical monitoring.

    View details for Web of Science ID 000085829700005

    View details for PubMedID 10724111

  • Alveolar capillary dysplasia: diagnostic potential for cardiac catheterization. Journal of perinatology Hintz, S. R., Vincent, J. A., Pitlick, P. T., Fineman, J. R., Steinhorn, R. H., Kim, G. E., Benitz, W. E. 1999; 19 (6): 441-446


    Alveolar capillary dysplasia is a rare cause of persistent pulmonary hypertension of the newborn. Infants with this condition die despite maximal medical intervention including inhaled nitric oxide therapy and extracorporeal membrane oxygenation. To date, diagnosis of this lethal condition was made by open lung biopsy or during postmortem examination. We examined the possibility that distinct cardiac catheterization findings could be used in the diagnosis of this lethal disorder.We present three infants with fatal persistent pulmonary hypertension of the newborn refractory to extracorporeal membrane oxygenation and inhaled nitric oxide therapy, two with postmortem autopsy confirmation of alveolar capillary dysplasia. Each infant underwent cardiac catheterization to complete the diagnostic evaluations.Significant right ventricular hypertension and normal pulmonary venous return were demonstrated, but a markedly diminished or absent capillary blush phase was noted in each infant. This finding is distinct from the normal capillary blush seen in infants with persistent pulmonary hypertension of the newborn of other etiologies.Cardiac catheterization may provide a useful alternative to tissue examination in the diagnosis of alveolar capillary dysplasia.

    View details for PubMedID 10685275

  • Bedside imaging of intracranial hemorrhage in the neonate using light: Comparison with ultrasound, computed tomography, and magnetic resonance imaging PEDIATRIC RESEARCH Hintz, S. R., Cheong, W. F., van Houten, J. P., Stevenson, D. K., Benaron, D. A. 1999; 45 (1): 54-59


    Medical optical imaging (MOI) uses light emitted into opaque tissues to determine the interior structure. Previous reports detailed a portable time-of-flight and absorbance system emitting pulses of near infrared light into tissues and measuring the emerging light. Using this system, optical images of phantoms, whole rats, and pathologic neonatal brain specimens have been tomographically reconstructed. We have now modified the existing instrumentation into a clinically relevant headband-based system to be used for optical imaging of structure in the neonatal brain at the bedside. Eight medical optical imaging studies in the neonatal intensive care unit were performed in a blinded clinical comparison of optical images with ultrasound, computed tomography, and magnetic resonance imaging. Optical images were interpreted as correct in six of eight cases, with one error attributed to the age of the clot, and one small clot not seen. In addition, one disagreement with ultrasound, not reported as an error, was found to be the result of a mislabeled ultrasound report rather than because of an inaccurate optical scan. Optical scan correlated well with computed tomography and magnetic resonance imaging findings in one patient. We conclude that light-based imaging using a portable time-of-flight system is feasible and represents an important new noninvasive diagnostic technique, with potential for continuous monitoring of critically ill neonates at risk for intraventricular hemorrhage or stroke. Further studies are now underway to further investigate the functional imaging capabilities of this new diagnostic tool.

    View details for Web of Science ID 000077706500009

    View details for PubMedID 9890608

  • Bedside functional imaging of the premature infant brain during passive motor activation OPTICAL TOMOGRAPHY AND SPECTROSCOPY OF TISSUE III, PROCEEDINGS OF Hintz, S. R., Benaron, D. A., Siegel, A. M., Zourabian, A., Boas, D. A. 1999; 3597: 221-229
  • Stationary headband for clinical time-of-flight optical imaging at the bedside PHOTOCHEMISTRY AND PHOTOBIOLOGY Hintz, S. R., Benaron, D. A., van Houten, J. P., Duckworth, J. L., Liu, F. W., Spilman, S. D., Stevenson, D. K., Cheong, W. F. 1998; 68 (3): 361-369


    Conventional brain-imaging modalities may be limited by high cost, difficulty of bedside use, noncontinuous operation, invasiveness or an inability to obtain measurements of tissue function, such as oxygenation during stroke. Our goal was to develop a bedside clinical device able to generate continuous, noninvasive, tomographic images of the brain using low-power nonionizing optical radiation. We modified an existing stage-based time-of-flight optical tomography system to allow imaging of patients under clinical conditions. First, a stationary head-band consisting of thin, flexible optical fibers was constructed. The headband was then calibrated and tested, including an assessment of fiber lengths, the existing system software was modified to collect headband data and to perform simultaneous collection of data and image reconstruction, and the existing hardware was modified to scan optically using this headband. The headband was tested on resin models and allowed for the generation of tomographic images in vitro; the headband was tested on critically ill infants and allowed for optical tomographic images of the neonatal brain to be obtained in vivo.

    View details for Web of Science ID 000075986500022

    View details for PubMedID 9747590

  • Automated quantitation of tissue components using real-time spectroscopy PHOTON PROPAGATION IN TISSUES III, PROCEEDINGS OF Benaron, D. A., Rubinski, B., Hintz, S. R., Duckworth, J. L., Murphy, A. L., Price, J. W., Liu, F. W., Otten, D. M., Stevenson, D. K., Cheong, W. F., Kermit, E. L. 1998; 3194: 500-511
  • Calibration of time-of-flight optical spectroscopy PHOTON PROPAGATION IN TISSUES III, PROCEEDINGS OF Duckworth, J. L., Benaron, D. A., Hintz, S. R., Liu, F. W., Stevenson, D. K., Cheong, W. F. 1998; 3194: 73-82
  • Brain functional imaging using time-of-flight optical spectroscopy PHOTON PROPAGATION IN TISSUES III, PROCEEDINGS OF Hintz, S. R., Benaron, D. A., Robbins, R., Duckworth, J. L., Murphy, A. L., Price, J. W., Liu, F. W., Stevenson, D. K., Cheong, W. F. 1998; 3194: 176-183
  • Automated classification of tissue by type using real-time spectroscopy OPTICAL BIOPSIES AND MICROSCOPIC TECHNIQUES II Benaron, D. A., Cheong, W. F., Duckworth, J. L., Noles, K., Nezhat, C., Seidman, D., Hintz, S. R., Levinson, C. J., Murphy, A. L., Price, J. W., Liu, F. W., Stevenson, D. K., Kermit, E. L. 1997; 3197: 99-107


    Tin protoporphyrin (SnPP) has been used to suppress hyperbilirubinemia in human neonates through inhibition of heme oxygenase. Some of the subjects exhibited mild erythema upon receiving phototherapy. SnPP and three proposed alternatives, tin mesoporphyrin (SnMP), zinc protoporphyrin (ZnPP) and zinc mesoporphyrin (ZnMP) are potential photosensitizers. We therefore studied the phototoxic effects of these compounds in the neonatal rat model. Fed Wistar rats (24-36 h old) were injected intraperitoneally with up to 40 mumol SnPP/kg body weight, 30 mumol SnMP/kg body weight, 60 mumol ZnPP/kg body weight, or 45 mumol ZnMP/kg body weight. The animals were placed over cool white light (20 microW/cm2/nm) for 12 h. Light exposure resulted in SnPP dose-dependent mortality, and the LD50 was determined to be 11.7 mumol/kg body weight. No deaths were observed in pups treated with up to 20 mumol SnMP/kg; treatment with 30 mumol SnMP/kg resulted in a 40% mortality rate. No fatalities were observed among the light-exposed ZnPP- or ZnMP-treated pups. No deaths were observed among control pups treated with the highest metalloporphyrin doses and kept in the dark; similarly, no mortality was observed in untreated light-exposed control animals. We conclude that (1) SnPP and SnMP are potentially fatal phototoxic substances in the neonatal rat; (2) ZnPP and ZnMP may be safer drugs for neonatal rats receiving light exposure, and (3) further studies are needed to fully assess the photobiological hazards of metalloporphyrin administration to humans.

    View details for Web of Science ID A1990DG27100006

    View details for PubMedID 2364856



    The purpose of this study was to investigate if oral metalloporphyrin treatment could suppress intestinal heme oxygenase (HO) activity and thus prevent HO-mediated heme degradation in this organ. Six hours after a single 40 mumol/kg oral dose of tin protoporphyrin (TP), zinc protoporphyrin (ZP), or heme to adult rats, no significant difference in the HO activity of the intestine was observed relative to control tissues. Moreover, the activity was not inhibited by in vitro exposure to 40 microM TP or ZP. Liver and spleen HO activity was also not significantly inhibited in vivo after oral administration of metalloporphyrins; however, in vitro exposure to TP or ZP decreased the HO activity of preparations from these organs significantly. Like adults, the intestinal HO activity of neonates was not inhibited effectively by oral administration of either metalloporphyrin. The results of subsequent in vitro exposure of control neonatal tissue preparations to ZP or TP was similar to those using adult tissue preparations. Even at 100 microM, only ZP seemed to have some in vitro inhibitory effect on the intestinal HO of suckling rats. We conclude that intestinal HO is less inhibitable by TP or ZP reaching the intestine via the stomach in concentrations at least 30-fold greater than those achieved after parenteral 40 mumol/kg doses, which cause significant hepatic and splenic HO inhibition. Intestinal absorption and enterohepatic circulation of heme, TP, and ZP do not seem to occur in amounts sufficient to consistently and significantly affect HO activity in liver or spleen.

    View details for Web of Science ID A1988Q638900019

    View details for PubMedID 3199276



    Single subcutaneous doses (25 mumol/kg body weight) of tin-protoporphyrin (TP), a potent competitive inhibitor or heme oxygenase (HO), were administered to both suckling and adult Wistar rats. The effect of TP on the carbon monoxide excretion rate (VeCO), an index of total bilirubin formation, and on in vitro carbon monoxide (CO) production by the small intestine were evaluated. Whereas the VeCO of the adult group was decreased (p less than 0.0005) after TP, that of the suckling rat was unchanged. Gradients of CO production along the small intestine were observed in sucklings as well as adults; however, these gradients were in opposite directions. Intestinal CO production was greatest in the adult duodenum, decreasing distally; conversely, the CO production was greatest in the suckling ileum, decreasing proximally. No significant difference in CO production between control and TP-treated adult intestinal mucosa was observed. In sucklings, a significant reduction of intestinal CO production in the TP-treated rats was detected in the duodenum only (p less than 0.05). The results suggest that suckling rats differ from adults in terms of the capacity to produce CO and the direction of the gradient of CO production along the intestine. We conclude that (1) TP may not substantially decrease the in vivo production of CO by the small intestine at a dose which inhibits hepatic and splenic heme oxygenase, and (2) because after a heme load, heme is excreted into the intestine after TP administration, heme-degrading, CO-producing processes in the intestine may contribute to an animal's VeCO under such conditions.

    View details for Web of Science ID A1988N081100006

    View details for PubMedID 3383729



    We assessed the in vivo and in vitro effects of antibiotics and tin-protoporphyrin (TP) on intestinal heme oxygenase (HO) activity using a gas chromatographic assay. This method measures the carbon monoxide produced from heme in the presence of NADPH. After in vivo administration of kanamycin (10 mg/kg body weight), ampicillin (200 mg/kg body weight) or neomycin (60 mg/kg body weight) with or without TP (65 mumol/kg body weight) to suckling rats, no significant difference in HO activity along the small intestine was observed. In vitro exposure of adult rat intestinal preparations to the antibiotics showed no significant decrease in HO activity between control and experimental tissue preparations. A concentration-dependent stimulatory effect of neomycin was observed. Subcutaneous administration of TP (25 mumol/kg body weight) to adult male Wistar rats revealed no significant inhibition of the intestine. However, in vitro addition of TP (12.5 microM) to the control tissue preparations of adult Wistar rats revealed highly significant inhibition in liver and spleen when compared to the unexposed control tissues. In contrast, when TP was added to control intestinal preparations no inhibition was observed. These findings suggest that suckling rat intestinal heme oxygenase is not inhibited by in vivo treatment with high concentrations of kanamycin, ampicillin, or neomycin. Furthermore, these antibiotics are not in vitro inhibitors of adult rat intestinal HO. Finally, adult rat intestinal HO is not inhibited either in vivo or in vitro by a concentration of TP that significantly inhibits liver and spleen activity.

    View details for Web of Science ID A1988L542200010

    View details for PubMedID 3340445



    We studied the effect of tin protoporphyrin (TP) on bilirubin production in adult Wistar rats by quantifying in vivo carbon monoxide (CO) excretion and the simultaneous excretion of biliary heme after common bile duct cannulation. A known amount of heme was injected intravenously as red blood cells (RBC) damaged with a sulfhydryl inhibitor, N-ethylmaleimide. The recovery of heme as CO or biliary heme in the cannulated animals was calculated as the molar percent of heme recovered over heme injected. For cannulated controls (n = 4), the recovery was 89 +/- 6% SD, and no heme appeared in bile. Cannulated rats treated with TP (n = 4) had 64 +/- 11% recovered as CO and 30 +/- 11% as heme in bile. Our findings suggest that TP is an effective in vivo inhibitor of exogenous heme catabolism and bilirubin production in adult rats. Furthermore, this inhibition results in increased excretion of heme into the bile proportional to the degree of inhibition.

    View details for Web of Science ID A1987G188100025

    View details for PubMedID 3694354



    The carbon monoxide excretion rate (VeCO) of groups of 1-day-old mice was measured after administration of two separate doses of 50 nmol of tin protoporphyrin (TP) per gram of body weight. The mean VeCO of the saline-treated control groups over the study period was 1.50 +/- 0.26 nmol/g/h, and that of the TP-treated groups was 1.35 +/- 0.29 nmol/g/h. Tin protoporphyrin treatment reduced the CO excretion by approximately 14% in 2-day-old mice over 24-48 h.

    View details for Web of Science ID A1987G021800007

    View details for PubMedID 3828416

Conference Proceedings

  • NEWBORN WITH CHOROIDAL FISSURE CYST AND PANHYPOPITUITARISM Chitkara, R., Rajani, A., Bernstein, J., Hudgins, L., Shah, S., Hahn, J., Hintz, S. LIPPINCOTT WILLIAMS & WILKINS. 2011: 166-166
  • Bilateral cystic lung disease in a monoamnionic twin of an anencephalic: A case of glial heterotopia in the lungs. Anderson, J. M., Adams, M. L., Morgan, T., Robinson, T., Enns, G. M., Keller, K. A., Sylvester, K. G., Hintz, S. R. LIPPINCOTT WILLIAMS & WILKINS. 2003: S119-S120

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