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Vol. 97, No. 2, 2010
Issue release date: February 2010
Section title: Original Paper
Free Access
Neonatology 2010;97:71–82
(DOI:10.1159/000232588)

SNAP-II and SNAPPE-II and the Risk of Structural and Functional Brain Disorders in Extremely Low Gestational Age Newborns: The ELGAN Study

Dammann O.a–c · Naples M.d · Bednarek F.d · Shah B.e · Kuban K.C.K.f · O’Shea T.M.g · Paneth N.h · Allred E.N.b · Leviton A.b
aDivision of Newborn Medicine, Floating Hospital for Children at Tufts Medical Center, and bNeuroepidemiology Unit, Departments of Neurology, Children’s Hospital and Harvard Medical School, Boston, Mass., USA; cPerinatal Neuroepidemiology Unit, Departments of Gynecology and Pediatrics, Hannover Medical School, Hannover, Germany; dDivision of Neonatology, University of Massachusetts Medical Center, Worcester, Mass., eBaystate Medical Center and Tufts Medical School, Springfield, Mass., fDivision of Pediatric Neurology, Boston Medical Center, Boston, Mass., gDepartment of Pediatrics, Wake Forest University Health Sciences, Winston-Salem, N.C., hDepartment of Epidemiology, College of Human Medicine, Michigan State University, East Lansing, Mich., USA
email Corresponding Author

Abstract

Background: Illness severity measures predict death and illnesses in the newborn. It is unknown how well they predict brain lesions evident on ultrasound scans or neurodevelopmental dysfunctions in preterm infants. Methods: A total of 1,399 inborn infants born before the 28th week of gestation were given Scores for Neonatal Acute Physiology (SNAP-II and SNAPPE-II) based on data collected within the first 12 h of admission to the intensive care unit and had a protocol brain ultrasound scan read independently by 2 sonologists. Of the surviving 1,149 infants, 1,014 (88%) had a neurologic examination at approximately 24 months post-term equivalent, and 975 (85%) had a Bayley Scales of Infant Development assessment. SNAP-II and SNAPPE-II were dichotomized at arbitrary cut-offs (30 for SNAP-II and 45 for SNAPPE-II), using the highest quartile and decile of the week of gestation as a cut-off, and at a Z score of >1 standard deviation from an external mean. Results: After adjustment for gestational age, high SNAP-II and SNAPPE-II scores predicted intraventricular hemorrhage, moderate/severe ventriculomegaly and echodense lesions in cerebral white matter. Only 2 SNAP-II extremes, the highest decile for gestational age and a Z score >1, also predicted echolucent lesions in the white matter. Neither SNAP-II nor SNAPPE-II predicted any statistically significant diagnosis of cerebral palsy. MDI and PDI scores <55 were consistently predicted by both high SNAP-II and SNAPPE-II, whereas scores in the 55–69 range were inconsistently predicted. High SNAP-II and SNAPPE-II inconsistently predicted a positive screen for autism spectrum disorder and small head circumference at 24 months. Conclusion: The physiologic instability in the first 12 post-natal hours identified by illness severity scores conveys information about the risks of brain damage and neurodevelopmental dysfunctions. This risk information might reflect postnatal characteristics in the causal chain. On the other hand, high SNAP scores might be indicators of immaturity and vulnerability.

© 2009 S. Karger AG, Basel


  

Key Words

  • Scores for Neonatal Acute Physiology
  • Extremely Low Gestational Age Newborns
  • Neurodevelopmental dysfunctions

References

  1. Schusterschitz N, Joannidis M: Predictive capacity of severity scoring systems in the ICU. Contrib Nephrol 2007;156:92–100.
  2. Afessa B, Gajic O, Keegan MT: Severity of illness and organ failure assessment in adult intensive care units. Crit Care Clin 2007;23:639–658.
  3. Pollack MM, Koch MA, Bartel DA, Rapoport I, Dhanireddy R, El-Mohandes AA, Harkavy K, Subramanian KN: A comparison of neonatal mortality risk prediction models in very low birth weight infants. Pediatrics 2000;105:1051–1057.
  4. Zupancic JA, Richardson DK, Horbar JD, Carpenter JH, Lee SK, Escobar GJ: Revalidation of the score for neonatal acute physiology in the Vermont Oxford Network. Pediatrics 2007;119:e156–e163.
  5. Kling PJ, Sullivan TM, Leftwich ME, Roe DJ: Score for neonatal acute physiology and phlebotomy blood loss predict erythrocyte transfusions in premature infants. Arch Pediatr Adolesc Med 1997;151:27–31.
  6. Escobar GJ, Shaheen SM, Breed EM, Botas C, Greene JD, Yoshida CK, Zupancic J, Newman TB: Richardson score predicts short-term adverse respiratory outcomes in newborns >/=34 weeks gestation. J Pediatr 2004;145:754–760.
  7. Hagadorn JI, Richardson DK, Schmid CH, Cole CH: Cumulative illness severity and progression from moderate to severe retinopathy of prematurity. J Perinatol 2007;27:502–509.
  8. Richardson DK, Phibbs CS, Gray JE, McCormick MC, Workman-Daniels K, Goldmann DA: Birth weight and illness severity: independent predictors of neonatal mortality. Pediatrics 1993;91:969–975.
  9. Mattia FR, deRegnier RA: Chronic physiologic instability is associated with neurodevelopmental morbidity at one and two years in extremely premature infants. Pediatrics 1998;102:E35.
  10. Richardson DK, Corcoran JD, Escobar GJ, Lee SK: SNAP-II, SNAPPE-II: simplified newborn illness severity and mortality risk scores. J Pediatr 2001;138:92–100.
  11. Teele R, Share J: Ultrasonography of Infants and Children. Philadelphia, Saunders, 1991.
  12. Kuban K, Adler I, Allred EN, Batton D, Bezinque S, Betz BW, Cavenagh E, Durfee S, Ecklund K, Feinstein K, Fordham LA, Hampf F, Junewick J, Lorenzo R, McCauley R, Miller C, Seibert J, Specter B, Wellman J, Westra S, Leviton A: Observer variability assessing US scans of the preterm brain: the ELGAN study. Pediatr Radiol 2007;37:1201–1208.
  13. Bayley N: Bayley Scales Of Infant Development-II. San Antonio, Psychological Corp., 1993.
  14. Robins DL, Fein D, Barton ML, Green JA: The Modified Checklist for Autism in Toddlers: an initial study investigating the early detection of autism and pervasive developmental disorders. J Autism Dev Disord 2001;31:131–144.
  15. CDC: CDC Growth Charts: United States 2007. Atlanta, CDC, 2007.
  16. Kuban KC, O’Shea M, Allred E, Leviton A, Gilmore H, DuPlessis A, Krishnamoorthy K, Hahn C, Soul J, O’Connor SE, Miller K, Church PT, Keller C, Bream R, Adair R, Miller A, Romano E, Bassan H, Kerkering K, Engelke S, Marshall D, Milowic K, Wereszczak J, Hubbard C, Washburn L, Dillard R, Heller C, Burdo-Hartman W, Fagerman L, Sutton D, Karna P, Olomu N, Caldarelli L, Oca M, Lohr K, Scheiner A: Video and CD-ROM as a training tool for performing neurologic examinations of 1-year-old children in a multicenter epidemiologic study. J Child Neurol 2005;20:829–831.
  17. Kuban KC, Allred EN, O’Shea TM, Paneth N, Pagano M, Leviton A, ELGAN Study Cerebral Palsy-Algorithm Group: An algorithm for diagnosing and classifying cerebral palsy in young children. J Pediat 2008;153:451–452.
  18. Palisano RJ, Hanna SE, Rosenbaum PL, Russell DJ, Walter SD, Wood EP, Raina PS, Galuppi BE: Validation of a model of gross motor function for children with cerebral palsy. Phys Ther 2000;80:974–985.
  19. Leviton A, Blair E, Dammann O, Allred E: The wealth of information conveyed by gestational age. J Pediatr 2005;146:123–127.
  20. Lilienfeld AM, Parkhurst E: A study of the association of factors of pregnancy and parturition with the development of cerebral palsy; a preliminary report. Am J Hyg 1951;53:262–282.
  21. Pasamanick B, Lilienfeld AM: Association of maternal and fetal factors with development of mental deficiency. I. Abnormalities in the prenatal and paranatal periods. J Am Med Assoc 1955;159:155–160.

    External Resources

  22. Ounsted M: Causes, continua and other concepts. I – the ‘continuum of reproductive casualty’. Paediatr Perinat Epidemiol 1987;1:4–7.
  23. Leviton A, Holmes LB, Allred EN, Vargas J: Methodologic issues in epidemiologic studies of congenital microcephaly. Early Hum Dev 2002;69:91–105.
  24. Begg MD, Parides MK: Separation of individual-level and cluster-level covariate effects in regression analysis of correlated data. Stat Med 2003;22:2591–2602.
  25. Kuban KC, O’Shea TM, Allred EN, Tager-Flusberg H, Goldstein DJ, Leviton A: Prevalence and correlates of screening positive on the Modified-Checklist for Autism in Toddlers (M-CHAT) in extremely low gestational age newborns. J Pediatrics 2009;154:535–540.
  26. Dammann O, Allred EN, Kuban KC, Van Marter LJ, Pagano M, Sanocka U, Leviton A: Systemic hypotension and white-matter damage in preterm infants. Dev Med Child Neurol 2002;44:82–90.
  27. Limperopoulos C, Bassan H, Kalish LA, Ringer SA, Eichenwald EC, Walter G, Moore M, Vanasse M, DiSalvo DN, Soul JS, Volpe JJ, du Plessis AJ: Current definitions of hypotension do not predict abnormal cranial ultrasound findings in preterm infants. Pediatrics 2007;120:966–977.
  28. Amin H, Singhal N, Sauve RS: Impact of intrauterine growth restriction on neurodevelopmental and growth outcomes in very low birthweight infants. Acta Paediatr 1997;86:306–314.
  29. Gross SJ, Kosmetatos N, Grimes CT, Williams ML: Newborn head size and neurological status: predictors of growth and development of low birth weight infants. Am J Dis Child 1978;132:753–756.

  

Author Contacts

Olaf Dammann
Floating Hospital for Children at Tufts Medical Center
Boston, MA 02111 (USA)
Tel. +1 617 636 0240, Fax +1 617 636 3309, E-Mail odammann@tufts-nemc.org

  

Article Information

Received: October 1, 2008
Accepted after revision: January 26, 2009
Published online: August 11, 2009
Number of Print Pages : 12
Number of Figures : 1, Number of Tables : 7, Number of References : 29

  

Publication Details

Neonatology (Fetal and Neonatal Research)

Vol. 97, No. 2, Year 2010 (Cover Date: February 2010)

Journal Editor: Halliday H.L. (Belfast), Speer C.P. (Würzburg)
ISSN: 1661-7800 (Print), eISSN: 1661-7819 (Online)

For additional information: http://www.karger.com/NEO


Copyright / Drug Dosage / Disclaimer

Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher or, in the case of photocopying, direct payment of a specified fee to the Copyright Clearance Center.
Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in goverment regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug.
Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.

Abstract

Background: Illness severity measures predict death and illnesses in the newborn. It is unknown how well they predict brain lesions evident on ultrasound scans or neurodevelopmental dysfunctions in preterm infants. Methods: A total of 1,399 inborn infants born before the 28th week of gestation were given Scores for Neonatal Acute Physiology (SNAP-II and SNAPPE-II) based on data collected within the first 12 h of admission to the intensive care unit and had a protocol brain ultrasound scan read independently by 2 sonologists. Of the surviving 1,149 infants, 1,014 (88%) had a neurologic examination at approximately 24 months post-term equivalent, and 975 (85%) had a Bayley Scales of Infant Development assessment. SNAP-II and SNAPPE-II were dichotomized at arbitrary cut-offs (30 for SNAP-II and 45 for SNAPPE-II), using the highest quartile and decile of the week of gestation as a cut-off, and at a Z score of >1 standard deviation from an external mean. Results: After adjustment for gestational age, high SNAP-II and SNAPPE-II scores predicted intraventricular hemorrhage, moderate/severe ventriculomegaly and echodense lesions in cerebral white matter. Only 2 SNAP-II extremes, the highest decile for gestational age and a Z score >1, also predicted echolucent lesions in the white matter. Neither SNAP-II nor SNAPPE-II predicted any statistically significant diagnosis of cerebral palsy. MDI and PDI scores <55 were consistently predicted by both high SNAP-II and SNAPPE-II, whereas scores in the 55–69 range were inconsistently predicted. High SNAP-II and SNAPPE-II inconsistently predicted a positive screen for autism spectrum disorder and small head circumference at 24 months. Conclusion: The physiologic instability in the first 12 post-natal hours identified by illness severity scores conveys information about the risks of brain damage and neurodevelopmental dysfunctions. This risk information might reflect postnatal characteristics in the causal chain. On the other hand, high SNAP scores might be indicators of immaturity and vulnerability.

© 2009 S. Karger AG, Basel


  

Author Contacts

Olaf Dammann
Floating Hospital for Children at Tufts Medical Center
Boston, MA 02111 (USA)
Tel. +1 617 636 0240, Fax +1 617 636 3309, E-Mail odammann@tufts-nemc.org

  

Article Information

Received: October 1, 2008
Accepted after revision: January 26, 2009
Published online: August 11, 2009
Number of Print Pages : 12
Number of Figures : 1, Number of Tables : 7, Number of References : 29

  

Publication Details

Neonatology (Fetal and Neonatal Research)

Vol. 97, No. 2, Year 2010 (Cover Date: February 2010)

Journal Editor: Halliday H.L. (Belfast), Speer C.P. (Würzburg)
ISSN: 1661-7800 (Print), eISSN: 1661-7819 (Online)

For additional information: http://www.karger.com/NEO


Article / Publication Details

First-Page Preview
Abstract of Original Paper

Received: 10/1/2008
Accepted: 1/26/2009
Published online: 8/11/2009
Issue release date: February 2010

Number of Print Pages: 12
Number of Figures: 1
Number of Tables: 7

ISSN: 1661-7800 (Print)
eISSN: 1661-7819 (Online)

For additional information: http://www.karger.com/NEO


Copyright / Drug Dosage

Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher or, in the case of photocopying, direct payment of a specified fee to the Copyright Clearance Center.
Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in goverment regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug.
Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.

References

  1. Schusterschitz N, Joannidis M: Predictive capacity of severity scoring systems in the ICU. Contrib Nephrol 2007;156:92–100.
  2. Afessa B, Gajic O, Keegan MT: Severity of illness and organ failure assessment in adult intensive care units. Crit Care Clin 2007;23:639–658.
  3. Pollack MM, Koch MA, Bartel DA, Rapoport I, Dhanireddy R, El-Mohandes AA, Harkavy K, Subramanian KN: A comparison of neonatal mortality risk prediction models in very low birth weight infants. Pediatrics 2000;105:1051–1057.
  4. Zupancic JA, Richardson DK, Horbar JD, Carpenter JH, Lee SK, Escobar GJ: Revalidation of the score for neonatal acute physiology in the Vermont Oxford Network. Pediatrics 2007;119:e156–e163.
  5. Kling PJ, Sullivan TM, Leftwich ME, Roe DJ: Score for neonatal acute physiology and phlebotomy blood loss predict erythrocyte transfusions in premature infants. Arch Pediatr Adolesc Med 1997;151:27–31.
  6. Escobar GJ, Shaheen SM, Breed EM, Botas C, Greene JD, Yoshida CK, Zupancic J, Newman TB: Richardson score predicts short-term adverse respiratory outcomes in newborns >/=34 weeks gestation. J Pediatr 2004;145:754–760.
  7. Hagadorn JI, Richardson DK, Schmid CH, Cole CH: Cumulative illness severity and progression from moderate to severe retinopathy of prematurity. J Perinatol 2007;27:502–509.
  8. Richardson DK, Phibbs CS, Gray JE, McCormick MC, Workman-Daniels K, Goldmann DA: Birth weight and illness severity: independent predictors of neonatal mortality. Pediatrics 1993;91:969–975.
  9. Mattia FR, deRegnier RA: Chronic physiologic instability is associated with neurodevelopmental morbidity at one and two years in extremely premature infants. Pediatrics 1998;102:E35.
  10. Richardson DK, Corcoran JD, Escobar GJ, Lee SK: SNAP-II, SNAPPE-II: simplified newborn illness severity and mortality risk scores. J Pediatr 2001;138:92–100.
  11. Teele R, Share J: Ultrasonography of Infants and Children. Philadelphia, Saunders, 1991.
  12. Kuban K, Adler I, Allred EN, Batton D, Bezinque S, Betz BW, Cavenagh E, Durfee S, Ecklund K, Feinstein K, Fordham LA, Hampf F, Junewick J, Lorenzo R, McCauley R, Miller C, Seibert J, Specter B, Wellman J, Westra S, Leviton A: Observer variability assessing US scans of the preterm brain: the ELGAN study. Pediatr Radiol 2007;37:1201–1208.
  13. Bayley N: Bayley Scales Of Infant Development-II. San Antonio, Psychological Corp., 1993.
  14. Robins DL, Fein D, Barton ML, Green JA: The Modified Checklist for Autism in Toddlers: an initial study investigating the early detection of autism and pervasive developmental disorders. J Autism Dev Disord 2001;31:131–144.
  15. CDC: CDC Growth Charts: United States 2007. Atlanta, CDC, 2007.
  16. Kuban KC, O’Shea M, Allred E, Leviton A, Gilmore H, DuPlessis A, Krishnamoorthy K, Hahn C, Soul J, O’Connor SE, Miller K, Church PT, Keller C, Bream R, Adair R, Miller A, Romano E, Bassan H, Kerkering K, Engelke S, Marshall D, Milowic K, Wereszczak J, Hubbard C, Washburn L, Dillard R, Heller C, Burdo-Hartman W, Fagerman L, Sutton D, Karna P, Olomu N, Caldarelli L, Oca M, Lohr K, Scheiner A: Video and CD-ROM as a training tool for performing neurologic examinations of 1-year-old children in a multicenter epidemiologic study. J Child Neurol 2005;20:829–831.
  17. Kuban KC, Allred EN, O’Shea TM, Paneth N, Pagano M, Leviton A, ELGAN Study Cerebral Palsy-Algorithm Group: An algorithm for diagnosing and classifying cerebral palsy in young children. J Pediat 2008;153:451–452.
  18. Palisano RJ, Hanna SE, Rosenbaum PL, Russell DJ, Walter SD, Wood EP, Raina PS, Galuppi BE: Validation of a model of gross motor function for children with cerebral palsy. Phys Ther 2000;80:974–985.
  19. Leviton A, Blair E, Dammann O, Allred E: The wealth of information conveyed by gestational age. J Pediatr 2005;146:123–127.
  20. Lilienfeld AM, Parkhurst E: A study of the association of factors of pregnancy and parturition with the development of cerebral palsy; a preliminary report. Am J Hyg 1951;53:262–282.
  21. Pasamanick B, Lilienfeld AM: Association of maternal and fetal factors with development of mental deficiency. I. Abnormalities in the prenatal and paranatal periods. J Am Med Assoc 1955;159:155–160.

    External Resources

  22. Ounsted M: Causes, continua and other concepts. I – the ‘continuum of reproductive casualty’. Paediatr Perinat Epidemiol 1987;1:4–7.
  23. Leviton A, Holmes LB, Allred EN, Vargas J: Methodologic issues in epidemiologic studies of congenital microcephaly. Early Hum Dev 2002;69:91–105.
  24. Begg MD, Parides MK: Separation of individual-level and cluster-level covariate effects in regression analysis of correlated data. Stat Med 2003;22:2591–2602.
  25. Kuban KC, O’Shea TM, Allred EN, Tager-Flusberg H, Goldstein DJ, Leviton A: Prevalence and correlates of screening positive on the Modified-Checklist for Autism in Toddlers (M-CHAT) in extremely low gestational age newborns. J Pediatrics 2009;154:535–540.
  26. Dammann O, Allred EN, Kuban KC, Van Marter LJ, Pagano M, Sanocka U, Leviton A: Systemic hypotension and white-matter damage in preterm infants. Dev Med Child Neurol 2002;44:82–90.
  27. Limperopoulos C, Bassan H, Kalish LA, Ringer SA, Eichenwald EC, Walter G, Moore M, Vanasse M, DiSalvo DN, Soul JS, Volpe JJ, du Plessis AJ: Current definitions of hypotension do not predict abnormal cranial ultrasound findings in preterm infants. Pediatrics 2007;120:966–977.
  28. Amin H, Singhal N, Sauve RS: Impact of intrauterine growth restriction on neurodevelopmental and growth outcomes in very low birthweight infants. Acta Paediatr 1997;86:306–314.
  29. Gross SJ, Kosmetatos N, Grimes CT, Williams ML: Newborn head size and neurological status: predictors of growth and development of low birth weight infants. Am J Dis Child 1978;132:753–756.