Frequency of elevations in markers of cardiomyocyte damage in otherwise healthy newborns.

Myocardial damage in infancy is a risk factor for eventual cardiac disease. Given that myocardial stress is greatest during the perinatal period and that the neonatal period is when most pediatric heart failure occurs, the aim of this study was to determine whether even otherwise healthy neonates might have subclinical myocardial damage and, if so, what characteristics might identify them. Umbilical cord and neonatal serum samples from 32 normal neonates were assayed for biomarkers of myocardial injury. No neonate had clinical evidence of cardiac or other abnormalities. Serum cardiac troponin T was elevated in 19 of 25 cords (76%) and in 16 of 17 neonates (94%); levels indicating myocardial infarction (> or =0.2 ng/ml) were found in 2 patients (1 umbilical cord and 1 neonatal sample). Creatine kinase-MB was elevated in 6 of 16 cords (38%) and in 8 of 15 neonates (53%). Cardiac troponin I was elevated in 11% and 17% of samples, myoglobin in 4% and 17%, and high-sensitivity C-reactive protein in 9% and 40%. Measures of myocardial injury were associated with longer hospitalization (r = 0.50, p = 0.04), non-Caucasian race (p = 0.012), lower birth weights (p = 0.014), positive maternal cervical cultures (r = 0.41, p = 0.046), and elevated high-sensitivity C-reactive protein (r = 0.66, p = 0.005). In conclusion, clinically occult myocardial injury appears to occur in some healthy newborns, although whether it is pathologic or not remains to be determined.

A randomized trial comparing long-term and short-term use of umbilical venous catheters in premature infants with birth weights of less than 1251 grams.

BACKGROUND: Umbilical vein and percutaneous central venous catheters are often used in preterm infants, but they can lead to complications, including infection. OBJECTIVE: We hypothesized that long-term umbilical vein catheter use would result in fewer infections than short-term umbilical vein catheter use followed by percutaneous central venous catheter placement. DESIGN/METHODS: Infants < or = 1250 g with umbilical vein catheters placed at admission were randomly assigned to a long-term (umbilical vein catheter up to 28 days) or short-term (umbilical vein catheter for 7-10 days followed by percutaneous central venous catheter) group. Catheter infection was defined as symptoms and > or = 1 positive blood culture for definite pathogens or >1 positive culture for other organisms, with a catheter in place. Clinically significant echocardiogram findings were defined as thrombi threatening vascular occlusion, crossing/blocking heart valves, or otherwise felt to be significant by the cardiologist. The primary outcome was time from birth to catheter infection, analyzed by the log-rank test. RESULTS: There were 106 subjects in the short-term group and 104 in the long-term group with birth weights of 915 +/- 198 and 931 +/- 193 g and gestational ages of 27.8 +/- 2.0 and 27.7 +/- 2.2 weeks, respectively. The distribution of time to catheter infection did not differ between the groups. The overall incidence of catheter infection was 13% in the short-term group and 20% in the long-term group. Median age at catheter infection was 11.5 days in the short-term group and 14 days in the long-term group. There were 7.4 infections per 1000 catheter-days in the short-term group and 11.5 per 1000 in the long-term group. Seven infections in the short-term group were in umbilical vein catheters, and 18 infections in the long-term group were in umbilical vein catheter. Echocardiograms detected 4 infants in the short-term group and 7 infants in the long-term group with significant thrombosis. All significant thrombi were at the site of the umbilical vein catheter tip. No thrombus caused hemodynamic compromise, no child had clinical symptoms of thrombosis, and none required therapy. Of the 45 small-for-gestational-age infants in the study, 9 developed thrombi (short-term group, 4; long-term group, 5). The incidence of thrombi was higher in the small-for-gestational-age group (20%) versus other study subjects (9%). There were no differences in time to full feedings or to regain birth weight or in the incidence of necrotizing enterocolitis or death. CONCLUSIONS: Infection and complication rates were similar between infants managed with an umbilical vein catheter in place for up to 28 days compared with infants managed with an umbilical vein catheter replaced by a percutaneous central venous catheter after 7 to 10 days. Umbilical vein catheter durations beyond the current Centers for Disease Control and Prevention-recommended limit of 14 days may be reasonable.

Surfactant administration by transient intubation in infants 29 to 35 weeks' gestation with respiratory distress syndrome decreases the likelihood of later mechanical ventilation: a randomized controlled trial.

OBJECTIVE: To assess, among premature infants with early respiratory distress syndrome (RDS), the effect of one dose of intratracheally administered surfactant followed by extubation to nasal continuous positive airway pressure (NCPAP) on subsequent mechanical ventilation (MV), when compared with NCPAP alone. STUDY DESIGN: Randomized, blinded trial in infants 29 to 35 weeks' gestation with mild-to-moderate RDS requiring supplemental oxygen and NCPAP. Infants were randomized to intubation, surfactant treatment, and immediate extubation (surfactant group N=52), or to no intervention (control group N=53). All infants were subsequently managed with NCPAP. RESULTS: Need for later MV was 70% in the control group and 50% in the surfactant group. Surfactant group subjects had lower inspired oxygen fraction (FiO(2)) after study intervention and were less likely to require subsequent surfactant. Overall surfactant use, duration of O(2) therapy, length of stay, and bronchopulmonary dysplasia were unaffected. CONCLUSION: Among premature infants with mild-to-moderate RDS, transient intubation for surfactant administration reduces later MV.

Pressure-regulated volume control ventilation vs synchronized intermittent mandatory ventilation for very low-birth-weight infants: a randomized controlled trial.

OBJECTIVE: To test the hypothesis that pressure-regulated volume control (PRVC), an assist/control mode of ventilation, would increase the proportion of very low-birth-weight infants who were alive and extubated at 14 days of age as compared with synchronized intermittent mandatory ventilation (SIMV). STUDY DESIGN: Ventilated infants with birth weight of 500 to 1249 g were randomized at less than 6 hours of age either to pressure-limited SIMV or to PRVC on the Servo 300 ventilator (Siemens Electromedical Group, Danvers, Mass). Infants received their assigned mode of ventilation until extubation, death, or meeting predetermined failure criteria. RESULTS: Mean +/- SD birth weights were similar in the SIMV (888 +/- 199 g, n = 108) and PRVC (884 +/- 203 g, n = 104) groups. No differences were detected between SIMV and PRVC groups in the proportion of infants alive and extubated at 14 days (41% vs 37%, respectively), length of mechanical ventilation in survivors (median, 24 days vs 33 days, respectively), or the proportion of infants alive without a supplemental oxygen requirement at 36 weeks' postmenstrual age (57% vs 63%, respectively). More infants receiving SIMV (33%) failed their assigned ventilator mode than did infants receiving PRVC (20%). Including failure as an adverse outcome did not alter the overall outcome (39% of infants in the SIMV group vs 35% of infants in the PRVC group were alive, extubated, and had not failed at 14 days). CONCLUSION: In mechanically ventilated infants with birth weights of 500 to 1249 g, using PRVC ventilation from birth did not alter time to extubation.