Surfactant treatment in premature infants with respiratory distress syndrome in Curacao

Surfactant replacement therapy for Respiratory Distress Syndrome (RDS) in premature neonates has been established as an effective treatment, although significant mortality and morbidity remain. In Curacao, surfactant became available as a therapeutic option in 1994. A retrospective cohort study was performed to describe the results of surfactant treatment in premature newborns with RDS in Curacao between 1994 and 1998. Of 429 infants admitted to the study hospital in this period, 7.5 percent (n=32) developed RDS and were treated with surfactant. Twenty-five per cent (n=8) of these infants died, most of them in the first year of surfactant treatment. Twenty-eight per cent (n=9) developed bronchopulmonary dysplasia (BPD), the most frequently observed complication. The highest incidence of BPD (44 percent) was found in the very low birth weight infants (750-1500 g); all infants with BPD were 27-30 weeks of gestational age. The duration of ventilator dependence was significantly associated with the development of BPD (p < 0.05). No other risk factors for complications during the treatment course could be identified. The mean time between birth and the first surfactant treatment was more than nine hours. In this study, we found low incidence rates of RDS and BPD, and a considerable mortality in surfactant treated surfactant treatment newborns. This pilot study shows that surfactant treatment of premature infants is feasible in Curacao. Earlier administration of surfactant, preferably within 2-3 hrs after birth, is expected to lower the risk of death and oxygen dependence.(Au)

Necrotising enterocolitis: A management protocol for developing countries

28 cases of necrotising enterocolitis (NEC) comprising 11 term and 17 preterm patients were diagnosed between January 1990 and December 1995 at the University Hospital of the West Indies (UHWI). Treatment was in accordance with a management protocol which emphasised aggressive screening of potential cases, early laparotomy for bowel perforation and primary anastomosis after small bowel resection. There were three deaths among the 13 cases of bowel perforation. Centres in developing countries can achieve rates of survival comparable to those in the developed world in babies with NEC weighing over 1000 grams by adopting the UHWI management protocol.(AU)

A multi-centre safety and efficacy trial of a preterm infant formula supplemented with long chain polyunsaturated fatty acids (LCP) (48 weeks PCA analysis)

LCP supplementation of premature infant formula has been shown to produce plasma and erythrocyte lipid profiles similar to human milk (HM)-fed preterm infants. Previous studies reported decreased growth with LCP supplemented formula. This prospective, double-blind, randomised, controlled, parallel trial compared safety, growth and phospholipid fatty acid (PFA) levels in preterm infants fed preterms formula with (L+) or without (Lo) LCP. The study consisted of Phase I: enrolment to 40 weeks (wk) postconceptual age (PCA); and Phase II: 40 to 48 wk PCA. Infants (birth weight 750-2000 g, 0-28 days of age) were fed L+ or L preterm formula, 24 Kcal/oz during Phase I, and 20 Kcal/oz during Phase II. A control group was exclusively HM-fed preterms who, if weaned at the end of Phase I, received L. HM and formula intake were unrestricted. Weight (wt), length (Lt), head circumference (OFC) and upper mid-arm circumference (MAC), and phospholipid profiles were measured at 40 and 48 wk PCA. Adverse events were monitored. 183/288 infants completed Phase II. There were no difference in growth rates between formula groups. At 48 wk PCA, mean PFA levels in infants fed L+ were similar to HM-fed and were significantly higher than the L fed group. Adverse events were similar between the 2 formula groups. The number of infants who were discontinued because of an adverse event was similar among all groups. In conclusion the LCP preterm infant formula is safe, support normal growth and maintains phospholipid profiles similar to HM-fed infants.(AU)

Urinary 5-L-oxoproline (pyroglutamic acid) excretion is greater in infants in Jamaican than in infants in England

OBJECTIVE: To determine the pattern of excretion in urine of 5-L-oxoproline, as a measure of glycine status, during the first six weeks of life in Jamaican infants. DESIGN: Spot samples of urine were collected from term and preterm infants at birth and longitudinally to four weeks of age, or at six weeks of age. 5-L-oxoproline was isolated by column chromatography and hydrolysed to L-glutamic acid, which was measured enzymatically and results expressed relative to creatinine excretion. SETTING: Maternity wards and postnatal clinic of the University Hospital of the West Indies. SUBJECTS: African-Caribbean infants, 19 term and 21 preterm, from birth to four weeks of age, and 79 term infants at six weeks of age. RESULTS: There was no difference between term and preterm infants. Excretion of 5-L-oxoproline increased progressively from birth, 141 æmol/mmol creatinine at four weeks of age. At six weeks of age, excretion was significantly greater than at birth or four weeks of age, 525 æmol/mmol creatinine. Compared with infant born in England, the excretion of 5-L-oxoproline was not different at birth, but was significantly greater in Jamaican infant at six weeks of age. CONCLUSIONS: Glycine status, indicated by increased excretion of 5-L-oxoproline, is marginal in Jamaican infants at six weeks of age, and this is possibly reflects a limitation in the endogenous biosynthesis of glycine due to a dietary limitation of folate or vitamin B-12. (AU)

Cardiac asystoles in preterm infants: are these a risk factor for SIDS? - abstract

In spite of significant advances in perinatal/neonatal care, preterm infants remain at high risk for unexplained death in infancy. Using continous documented monitoring as a predischarge screen for persistance of apneas and bradycardias in preterm infants (mean GA 30.5 weeks) prior to hospital discharge, 21 of 332 infants (6.3 per cent) had asystolic events defined as cardiac pauses > 3 seconds. All affected infants had a history of O2 desaturation < 85 per cent and/or colour change in the weeks prior to event monitor screening. Concurrent 72-hour Holter monitoring confirmed sinus pauses of 3 - 10 seconds. Echocardiogram revealed pulmonary artery branch stenosis in 9 of the 21 infants, but no other structural abnormalities. Gastroesophageal reflux was diagnosed by pH probe and/or Milk-Scan in all 21 infants; clinical symptoms improved after specific therapy but asystoles and bradycardias persisted. All infants were followed with home monitoring until asystole-free for 2 months. Asystoles decreased with age: with a mean of 33.7 events/wk at 36 wks post-conceptional age, 24.7 at 47 wks and only 1 infant had asystolic events beyond 58 weeks. Pacemakers were recommended in 3 infants, but only placed in one. None of the infants died. Conclusion: asystolic events occur in preterm infants without significant anatomical cardiac abnormalities and can be diagnosed by continuous documented monitoring. Resolution occurs spontaneously, but long-term cardiology follow-up is necessary to determine later outcome and complications. The significance of these events and their relationship to sudden death in infancy need to be explored (AU)

True apenas as a first symptom of viral upper respiratory tract infection in preterm infants on home documented event monitors - abstract

Between January, 1992 and September, 1994 all preterm infants followed in the Neonatal High-risk Follow-up Clinic were prospectively evaluated for apneas and/or bradycardias associated with upper respiratory tract infection (URI). 52 infants (mean post-conceptional age 39.2 weeks) had increased apneas with URI. All infants had nasal stuffiness; dry cough was present in 10 (19 percent) and 12 (23 percent) had low grade fever, 16 (31 percent) slept more and had to be awakened for feeds. Respiratory syncytial virus (RSV) antigen was negative in 40; 12 were RSV positive. All bacterial cultures were negative. Hospitalization was necessary in 23 infants (5 with RSV and 19 without RSV). The 9 infants on xanthine therapy had therapeutic levels. The onset of apneas and bradycardias was abrupt, apneas (by report and monitor data) preceded parental suspicion of URI. Monitor data showed 0-5 apneas > 20 sec. per during URI. In addition, 22 percent of infants demonstrated bradycardias with heart rates < 80 minute with URI. Continous pulse oximetry on hospitalized infants showed baseline levels of 93-98 percent with frequent desaturations as low as 78 percent, requiring O 2 supplementation in 14 infants and Xanthine therapy in 16. None of the infants expired. Ex-preterm infants on home monitoring for persistence of apnea of prematurity may be at a high risk for severe apneas and bradycardias with viral upper respiratory infection, and require close surveillance whenever exposed. The relationship of this to SIDS/ALTE needs to be investigated (AU)

Perinatal deaths as a result of immaturity in Jamaica

During the 12-month period from 1 September 1986 to 31 August 1987 an attempt was made to collect information on all perinatal deaths occurring on the island of Jamaica. Of the 2069 late fetal and early neonatal deaths identified, 19 percent fell into the Wigglesworth definition of 'deaths from immaturity'. Twins were 11 times more likely to die of immaturity than were singletons, and twins comprised 18 percent of all deaths in this group. Comparison of the singleton deaths from immaturity, with 9919 singletons born on the island during the 2-month period of September and October 1987 and who survived the first 7 days, revealed several stong risk factors. These included history of previous miscarriages, stillbirth, early neonatal death or preterm delivery, and complications of bleeding and hypertension (highest diastolic, proteinuria and eclampsia all having independent associations). None of these factors 'explained' a strong negative relationship with the number of young children in the household. There was an apparent protective effect of maternal folic acid ingestion which warrants further investigation (Summary)

Antenatal and perinatal care in Jamaica: do they reduce perinatal death rates?

Information concerning 9919 singleton pregnancies delivered in Jamaica in the 2-month period of September and October 1986 and surviving the early neonatal period were compared with 1847 singleton perinatal deaths occurring in the 12-month period from 1 September 1986 to 31 August 1987, classified according to the Wigglesworth schema. Logistic regression was used to assess features of antenatal and intrapartum care that were associated with the different groups of perinatal death after taking account of environmental, maternal and medical factors. In Jamaica, 67 percent of all mothers took iron during pregnancy. There mothers appeared to have a lower risk of perinatal death. This does not appear to be an artefact related to the gestation at which the mother delivers, and was particularly associated with antepartum fetal deaths. Commencement of antenatal care in the first trimester appeared to reduce the risk of all perinatal deaths, and for intrapartum asphyxia in particular. It is speculated that the mechanism may involve early detection and treatment of anaemia and syphilis. Quality of perinatal care available in the area of residence, as measured by the presence of consultant obstetricians and a paediatric consultant unit, is shown to be significantly related to a reduction in deaths from intrapartum asphyxia, but it appeared no to be related to antepartum fetal deaths (Summary)

Medical conditions present during pregnancy and risk of perinatal death in Jamaica

In an attempt to identify causes of perinatal mortality and hence devise preventative strategies on the island of Jamaica, a study was made of the 1847 singleton perinatal deaths occuring over the 12 month period between 1 September 1986 and 31 August 1987. Complications of the pregnancy were elicited by questioning the mothers as well as abstracting data from the antenatal and clinical obstetric records. The deaths were classified using the Wigglesworth categorisation and the three largest groups were chosen for special study: antepartum fetal deaths, deaths of live births from immaturity and deaths from intrapartum asphyxia. The medical features of the pregnancies were compared with data similarly obtained from 9919 women delivering singletons in the 2 months of September and October 1986 and who survived the first week of life. Unadjusted statistically significant associations were found with maternal syphilis, vaginal infection or discharge, bleeding in the first two trimesters, bleeding in the third trimester, lowest haemoglobin, highest diastolic and first diastolic blood pressures, highest level of proteinuria, diabetes and antenatal eclampsia. Logistic regression taking account of social, environmental and health behaviour variables showed the following significant relationships. Antepartum fetal death was associated with adjusted odds ratio (AOR) for syphilis 2.88[95 percent confidence interval (CI): 1.91, 4.32], bleeding in third trimester 3.86 [2.73, 5.44], highest diastolic blood pressure (P<0.0001), highest level of proteinuria (P<0.0001), lowest Hb (P<0.0001) and antenatal eclamptic fits AOR 4.62 [1.47, 14.50]. Deaths from immaturity were independently associated with bleeding < 28 weeks AOR 3.50 [2.39, 5.13], bleeding 28+ weeks AOR 1.93 [1.16, 3.22], highest diastolic blood pressure (P<0.01) and highest level of proteinuria (P<0.0001). Infection featured in deaths associated with intrapartum asphyxia, with syphilis AOR 2.17 [1.44, 3.26] and vaginal infection/discharge (P<0.01) independently associated; other strong associations were bleeding <28 weeks AOR 2.10 [1.57, 2.81], bleeding 28+ weeks AOR 2.32 [1.62, 3.33], highest diastolic blood pressure(P0.0001), first diastolic blood pressure (P<0.0001) and antenatal eclampsia AOR 6.70 [2.63, 17.13]. For all perinatal deaths combined, independent features were syphilis AOR 2.06 [1.49, 2.85], vaginal infection/discharge (P<0.001), bleeding < 28 weeks AOR 2.01 [1.60, 2.53], bleeding 28+ weeks AOR 2.65 [2.02, 3.48], highest diastolic blood pressure (P<0.0001), and antenatal eclampsia AOR 4.22[1.76, 10.14]. The results help identify areas for monitoring and identifying pregnancies at highest risk (Summary)

Does maternal behaviour influence the risk of perinatal death in Jamaica?

Features of behaviour of mothers of singleton perinatal deaths collected over the 12-month period from 1 September 1986 to 31 August 1987 were compared with 9919 mothers of singleton infants born in September and October 1986 and surviving the first week of life, as part of the Jamaican Perinatal Mortality Survey. For perinatal deaths as a whole, and in the presence of maternal age and social environmental features, logistic regression analyses showed that the following were independently related with higher risk of mortality: (1) deliberately trying to get pregnant; (2) ever having used Depo Provera; (3) not drinking alcohol in pregnancy; and (4) smoking cigarettes in pregnancy. There were no associations with coital frequency, ever using the contraceptive pill or smoking ganja (cannabis). Deaths were classified using the Wigglesworth scheme, and separate analyses carried out for the three major groups-antepartum fetal deaths, deaths from immaturity and deaths from intrapartum asphyxia. Antepartum fetal deaths were at increased risk if (1) mothers were deliberately trying to get pregnant or (2) they had ever used Depo Provera. Deaths from immaturity were not associated with any health behaviour variables. Deaths from intrapartum asphyxia were more likely if (1) the mother was deliverately trying to get pregnant or (2) she had never used and used and intrauterine contraceptive device (Summary)

Association between social and environmental factors and perinatal mortality in Jamaica

Social and environmental factors in Jamaica were compared between 9919 mothers delivering in a 2-month period a singleton who survived the early neonatal period and 1847 mothers who were delivered of a singleton perinatal death in a continuous 12-month period. Logistic regression showed independent positive statistically significant increased odds of having a perinatal death among mothers who lived in rural parishes, older mothers (aged 30+), single parents, no other children in the household, large number of adults in the household, mother unemployed, the major wage earner of the household not being in a managerial, professional or skilled non-manual occupation, the household not having sole use of toilet facilities, smaller mothers and those classified as obese or undernourished. Variations were found for different categories of death. Intrapartum asphyxia deaths were not related to union (marital) status, occupation of major wage earner, number of adults nor to the use of the toilet. Antepartum fetal deaths did not vary significantly with occupation of major wage earner or maternal height, but did show a relationship with maternal education, mothers with lowest levels having reduced risk. Deaths from immaturity were significantly related only to occupation of major wage earner, number of children in the household, number of social amenities available (negative relationships) and maternal age (<17 at highest risk). In conclusion there was little to indicate that social deprivation per se was related to perinatal death, although specific features of the environment showed strong relationships (AU)

Maternal determinants of perinatal mortality and of intrauterine growth retardation and preterm delivery

Marked disparities in rates of perinatal mortality continue to persist between developed and developing countries and even within developed countries. Major contributors to the differences across countries are the widely differing rates of preterm births and intrauterine growth retardation that are major determinants of perinatal mortality (1). Maternal conditions and factors play a major role in these adverse birth outcomes. This chapter highlights some of these, which include demographic factors, maternal diseases and conditions, social status, adverse health behaviors, and the use of prenatal care. Where possible, differences between developed and developing countries are highlighted. (AU)

Neonatal mortality determinants in Jamaica

The Jamaican Perinatal Survey included among its objectives the quantification of the island's neonatal mortality rate, the identification of the causes of these deaths (Wigglesworth Classification), and the determination of characteristics of both mother and infant that are associated with increased mortality. A death questionaire was completed on babies who were born between September 1986 and August 1987, and who died in the neonatal period throughout the island of Jamaica. The neonatal mortality rate was 17.9 per 1000 live births with early and late rates of 16.0 and 1.9 per 1000 respectively. The major contributors to neonatal demise were prematurity and intrapartum asphyxia (74 per cent). Twins had a seven- fold greater risk of dying than singletons. Babies born to mothers under 15 years had a four-fold greater risk of dying than those of mothers 25-29 years. The neonatal mortality rate for Jamaica is high, with room for improvement, particularly in the prevention of perinatal asphyxia. (AU)

Hypertensive disease in pregnant women delivering before 34 weeks gestation - abstract

Preterm delivery (delivery before 34 weeks gestation) accounts for the major part of perinatal mortality and morbidity which are worsened when hypertension is superimposed. This study analyses maternal characteristics, peripartum factors and mode of delivery in 419 consecutive preterm deliveries over the period January, 1986 to December 1989, in which 69 gravidae were hypertensive (diastolic blood pressure > 90 mm Hg) and the rest normotensive. Of the 69 hypertensive patients, 52 (75 per cent) had uncontrollable hypertension necessitating delivery and 19 (28 per cent) developed convulsions. The hypertensive mother was older, of higher parity, and had a higher frequency of previous stillbirths and Caesarean sections (CS). Acute foetal distress in labour, NST (Non-reactive non-stress test) and IUGR (Intrauterine growth retardation) were all more frequent in the hypertensive pregnancy (Table given). Ethnic origin was not associated with occurrence of hypertension in pregnancy. The overall perinatal mortality was 36 per cent in this series; and there were no maternal deaths (AU)

Neonatal acquired immune deficiency syndrome (AIDS)

The number of cases of perinatally acquired immune defiency syndrome (AIDS) may increase as the prevalence of human immunodeficiency virus (HIV)-positive women increases. Physicians involved in the care of neonates must therefore be aware of the modes of transmisson, clinical manifestations, and methods of neonatal AIDS. We report the first case of congenital AIDS in a premature infant admitted to our Neonatal Intensive Care Unit (NICU). In this report, we highlight some atypical clinical manifestations of the disease and discuss modes of transmission, epidemiology, preventive measures and some controversial aspects of management of the mother and infant (AU)

Neonatal mortality determinants in Jamaica - abstract

The Perinatal Survey included among its objectives the quantification of the island's neonatal mortality rate, the identification of the causes of these deaths and the determination of characteristics of both mother and infant that are associated with an increased risk of death, so that intervention and reduction would be possible. Data were collected on babies born between September 1986 and August 1987 and who died in the first 28 days of life, anywhere in Jamaica. Postmortems were performed where feasible. A death questionnaire provided information on date, place and time of death, age of mother and classification of death by the Wigglesworth method. Additional social, environmental, medical, obstetric and neonatal data were included on a main questionnaire. Data from the death questionnaire were analyzed, using SPSS. There were 950 neonatal deaths identified over the 12-month period of study. The neonatal mortality was 17.9 per 1,000 live births, with the early and late neonatal mortality rates being 16.0 and 1.9 per 1,000 respectively. The major contributors to neonatal death were prematurity and perinatal asphyxia (73.5 percent). The majority of deaths (56.2 percent) occurred in the first day of life. Twins had a sevenfold greater risk of dying than singletons, with 58.6 per cent of deaths among second twins. One-third of neonatal deaths were to teenage mothers although they accounted for 26 percent of total births. Babies born to mothers under 15 years of age were four times more likely to die than infants of mothers 25 - 29 years of age. The neonatal death rate in Jamaica is high with room for improvement, particularly in the prevention of perinatal asphyxia and the early identification and management of mothers whose infants are at high risk of neonatal death (AU)

Immunization of the premature newborn - abstract

The human immune system is not fully competent at the time of birth and is even more immature with earlier gestational age at delivery. Nothing is known about the ability of the immune system of the premature newborn to respond to immunization. We are studying the immune response of prematures at Mt. Hope Maternity Hospital, Trinidad to determine the optimal time of immunization. Neonates are divided into four groups based on birth weight. Each group is further subdivided into two subgroups, one immunized 6-8 weeks after birth and the other at 6-8 weeks after calculated full term. Immunization includes diphtheria, pertussis, tetanus and polio. Immune response is measured by tetanus toxoid antibody and cellular reponses. To date, 50 neonates have been entered into the study. Thirty-nine have completed the primary series of three immuniations and 27 have had at least one follow-up sample. Twelve of the neonate were less than 1500/gm at birth. Eleven of the 12 have had appropriate antibody responses. The baby who did not respond had a high titre of passive maternal antibody at birth (4.2 i.u./ml) and the absence of reponse may be related to this. No differences in reponses habe been observed with early and late immunization. Cellular responses to tetanus toxoid were variable. Forty-two per cent of babies showed in-vitro reativity to tetanus at birth. However, only 30 per cent were reactive following the primary immunization series. Responses to streptococcal antigens fluctuated with the tetanus reponses, suggesting no specificity in the blastogenic response in these neonates (AU)

Nitrogen metabolism in preterm infants fed human donor breast milk: the possible essentiality of glycine

Nitrogen metabolism was studied in three preterm infants (mean gestation 32 wk) by the method of consecutive metabolic balance. The absorption and retention of nitrogen from breast milk was measured, and protein turnover, synthesis, and breakdown were calculated from isotopic plateau of urinary urea and ammonia using an intermittent oral administration of 15N-glycine. Weight gain and nitrogen retention were compared with the weight gain and nitrogen accumulated for a foetus of equivalent gestational age in utero (AU)

Prognosis for extremely low birth weight babies in Jamaica

The status of 35 children who weighed less than 1,500 grams when born at the University Hospital of the West Indies, Kingston, between 1969 and 1973, was compared with that of 37 matched normal birth weight controls. Follow-up was in February and March, 1975, two to six years after birth. Low birth weight children were socially disadvantaged and physically smaller when compared with controls. No significant physical handicaps were identified. More of the low birth weight children failed to pass a developmental screening test as "normal" (8/35) than controls (2/37). (Xý=4.35,p<0.04). However, only 46 percent of surviving extremely low birth weight babies were examined, and the possibility of handicap in the untraced minority remains (AU)