University of Michigan
Department of Pediatrics
Evidence-Based Pediatrics Web Site

Question

• A 1100 gm infant has sustained a grade IV intraventricular hemorrhage (IVH) and is getting twice daily lumbar punctures.  Does this therapy decrease future morbidity or mortality?

Clinical Bottom Lines

1. IVH occurs in 35-50% of infants <35 weeks gestational age.
2. Of these 5-15% develop severe progressive hydrocephalus and around half require shunt placement.
3. The 2 studies that are summarized revealed no statistical difference in outcome in regards to hydrocephalus and the need for shunt placement, poor neurological outcome, or death with the therapy of serial lumbar punctures.^1,2

Summary of Key Evidence

1. In a study by Anwar, 47 patients with grades III, IVH were placed in a randomized, prospective controlled study with blinding of ultrasonagraphers in evaluating lumbar punctures vs. supportive care only.  The 2 groups were equal at the start of the study and accounted for in the end.¹
2. The outcomes of the Anwar study revealed no differences of shunt placements hydrocephalus, or death in relation to treatment, severity of IVH, or in the quantity of CSF removed from treatment group.¹
3. In the Dykes study, the medical management arm included 38 patients with asymptomatic severe PHH who were randomly assigned in a prospective controlled trial.  The study does not mention if the investigators were blinded.  They were given supportive care vs. daily lumbar punctures.²
4. The outcomes in the Dykes study revealed no difference in poor neurological outcome or death when comparing supportive care vs. serial lumbar punctures.²

Additional Comments

• It was noted in the Dykes study that the outcomes were statistically significant in relation to severity of IVH and gestational age <30 weeks.
• It does not appear that early removal of protein and blood from CSF by serial lumbar punctures reduces morbidity/mortality in patients with asymptomatic hydrocephalus.
• Lumbar punctures have been shown effective in delaying the need for shunt placement as the infant grows to a size acceptable for surgery.
• Incidence rate of meningitis in patients requiring serial lumbar punctures has been reported as 5-15%.

Citation

1. Anwar M, Kadam S, Hiatt M, Heygi T.  Serial lumbar punctures in prevention of post-hemorrhagic hydrocephalus in pre-term infants.  Journal of Pediatrics, 1985; 170:446-450.
2. Dykes FD, Dunbar B, Lazarra A, Ahmann P.  Post-hemorrhagic hydrocephalus in high-risk pre-term infants: Natural history, management, and long-term outcome.  Journal of Pediatrics, 1989; 114:611-618.

CAT Author: James Barry, MD

CAT Appraisers: John Frohna, MD

Date appraised: June 5, 2000