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Research Article

Abnormal Cortical Development after Premature Birth Shown by Altered Allometric Scaling of Brain Growth

  • Olga Kapellou,

    Affiliation: Department of Paediatrics, Imperial College, Hammersmith Hospital, London, United Kingdom

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  • Serena J Counsell,

    Affiliation: Division of Clinical Sciences, Imperial College, and MRC Clinical Sciences Centre, Hammersmith Hospital, London, United Kingdom

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  • Nigel Kennea,

    Affiliation: Department of Paediatrics, Imperial College, Hammersmith Hospital, London, United Kingdom

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  • Leigh Dyet,

    Affiliations: Department of Paediatrics, Imperial College, Hammersmith Hospital, London, United Kingdom, Division of Clinical Sciences, Imperial College, and MRC Clinical Sciences Centre, Hammersmith Hospital, London, United Kingdom

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  • Nadeem Saeed,

    Affiliation: Division of Clinical Sciences, Imperial College, and MRC Clinical Sciences Centre, Hammersmith Hospital, London, United Kingdom

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  • Jaroslav Stark,

    Affiliation: Department of Mathematics, Imperial College, London, United Kingdom

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  • Elia Maalouf,

    Affiliation: Department of Paediatrics, Imperial College, Hammersmith Hospital, London, United Kingdom

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  • Philip Duggan,

    Affiliation: Department of Paediatrics, Imperial College, Hammersmith Hospital, London, United Kingdom

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  • Morenike Ajayi-Obe,

    Affiliation: Department of Paediatrics, Imperial College, Hammersmith Hospital, London, United Kingdom

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  • Jo Hajnal,

    Affiliation: Division of Clinical Sciences, Imperial College, and MRC Clinical Sciences Centre, Hammersmith Hospital, London, United Kingdom

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  • Joanna M Allsop,

    Affiliation: Division of Clinical Sciences, Imperial College, and MRC Clinical Sciences Centre, Hammersmith Hospital, London, United Kingdom

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  • James Boardman,

    Affiliations: Department of Paediatrics, Imperial College, Hammersmith Hospital, London, United Kingdom, Division of Clinical Sciences, Imperial College, and MRC Clinical Sciences Centre, Hammersmith Hospital, London, United Kingdom

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  • Mary A Rutherford,

    Affiliation: Division of Clinical Sciences, Imperial College, and MRC Clinical Sciences Centre, Hammersmith Hospital, London, United Kingdom

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  • Frances Cowan,

    Affiliations: Department of Paediatrics, Imperial College, Hammersmith Hospital, London, United Kingdom, Division of Clinical Sciences, Imperial College, and MRC Clinical Sciences Centre, Hammersmith Hospital, London, United Kingdom

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  • A. David Edwards mail

    To whom correspondence should be addressed. E-mail: david.edwards@imperial.ac.uk

    Affiliations: Department of Paediatrics, Imperial College, Hammersmith Hospital, London, United Kingdom, Division of Clinical Sciences, Imperial College, and MRC Clinical Sciences Centre, Hammersmith Hospital, London, United Kingdom

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  • Published: August 01, 2006
  • DOI: 10.1371/journal.pmed.0030265

Reader Comments (1)

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Effect of corticosteroids or immediate cord clamping?

Posted by plosmedicine on 30 Mar 2009 at 23:58 GMT

Author: David Hutchon
Position: Consultant Obstetrician and Gynaecologist
Institution: Memorial Hospital, Darlington
E-mail: DJRHutchon@Postmaster.co.uk
Additional Authors: Ben O Ononeze
Submitted Date: August 03, 2006
Published Date: August 14, 2006
This comment was originally posted as a “Reader Response” on the publication date indicated above. All Reader Responses are now available as comments.

The authors report that conventional antenatal corticosteroid therapy was received by all mothers. While antenatal steroids reduce morbidity from RDS and probably neonatal mortality (1), there is also evidence that the steroid also has an effect on brain development.(2) Multiple courses of steroids have been shown to reduce head size.(3) Multiple doses of steroids are not now recommended but may have been used before 2000. How many of these mothers received multiple courses? Further if multiple courses have a demonstrable effect, it is quite feasible that there is a minor effect on the brain by a single course.

The findings of this paper are consistent with capillary vascular damage occurring at delivery. 73 % of these babies were delivered by Caesarean Section. We are not suggesting that the Caesarean delivery in itself would have an adverse effect but almost certainly all these babies would have had the cord clamped immediately at delivery. Clamping the cord immediately at birth, especially before the first breath is taken, is far from physiological and interferes with the transformation from fetal to adult circulation. It is justified by the need to resuscitate the baby and maintain its temperature. The intervention of immediate clamping the cord needs to be justified by evidence. This evidence has never been sought. Indeed there is considerable evidence emerging that it is harmful to the term (4), the preterm (5) and very preterm infants (6). Immediate umbilical cord clamping is the result of tradition and is carried out without thought by the vast majority of obstetricians and paediatricians. In the 1980s Peter Dunn, working in Bristol, demonstrated a technique of delivery at Caesarean Section for the preterm baby which avoided the hazards of immediate cord clamping. (7) This was before the use of antenatal corticsteroids or surfactant yet the survival rates were excellent.

We would like to alert the clinical community to two issues. Currently antenatal corticosteroids are given much too readily, often when there is very little risk of preterm birth. Secondly the cord must not be clamped immediately at delivery, especially Caesarean Section, and ways to allow resuscitation of the neonate with the cord intact must be routine clinical practice. Further research is needed to determine how much of the brain damage demonstrated in this paper could be the result of antenatal corticosteroids and immediate cord clamping.

References

1. David JR Hutchon Corticosteroids may not be very effective. (22 April 2006) eBMJ 2006; 332: 924-925 Rapid Response

2. James A. Thorp, MD, Philip G. Jones, MS, Eric Knox, MD and Reese H. Clark, MD Does Antenatal Corticosteroid Therapy Affect Birth Weight and Head Circumference? Obstetrics & Gynecology 2002;99:101-108

3. French NP, Hagan R, Evans SF, Godfrey M, Newnham JP. Repeated antenatal corticosteroids: size at birth and subsequent development.
Am J Obstet Gynecol. 1999 Jan;180(1 Pt 1):114-21.

No competing interests declared.