Necrotizing enterocolitis and its association with the neonatal abstinence syndrome.

OBJECTIVE: The purpose of this study was to describe an identified association between necrotizing enterocolitis (NEC) and prenatal opioid exposure with neonatal abstinence syndrome (NAS) in late preterm and full-term neonates. STUDY DESIGN: In this single-center retrospective cohort study, we analyzed inborn neonates with the diagnosis of NEC discharged from 2012 through 2017. We compared infants with NEC > 35 weeks' gestation to those with NEC<35 weeks' gestation. We compared gestational age, birth weight, age of onset of symptoms, and incidence of prenatal drug exposure between groups. Significance was determined using Mann-Whitney and Fisher's exact tests. RESULTS: Over the study period, 23 infants were identified with NEC, 9 (39%) were babies > 35 weeks at birth and 14 (61%) < 35 weeks. Those > 35 weeks had a higher birth weight, earlier onset of symptoms, and a higher percentage of prenatal exposure to opioids compared to those < 35 weeks' gestation. We further described seven infants with late gestational age onset NEC associated with prenatal opioid exposure. CONCLUSIONS: In this cohort of infants with NEC discharged over a 6 year period we found a higher than expected percentage of infants born at a later gestational age. We speculate that prenatal opioid exposure might be a risk factor for NEC in neonates born at > 35 weeks.

A management strategy that reduces NICU admissions and decreases charges from the front line of the neonatal abstinence syndrome epidemic.

OBJECTIVE: The purpose of this study was to test a specialized needs-based management model for a high volume of babies born with neonatal abstinence syndrome (NAS) while controlling costs and reducing neonatal intensive care unit (NICU) bed usage. STUDY DESIGN: Data were analyzed from inborn neonates >35 weeks' gestational age with the diagnosis of NAS (ICD9-CM 779.5), requiring pharmacologic treatment and discharged from 2010 through 2015. Significance was determined using Kruskal-Wallis and Mann-Whitney as well as χ2 for trend. RESULTS: NAS requiring medication treatment increased from 34.1 per 1000 live births in 2010 to 94.3 per 1000 live births in 2015 (P<0.0001 for trend). Hospital charges were significantly different in the three described locations (P<0.0001). Median per patient hospital charges for medically treated NAS were $90 601 (interquartile range (IQR) $64 489 to $128 135) for NAS patients managed in the NICU, $68 750 (IQR $44 952 to $92 548) for those managed in an in-hospital dedicated unit and $17 688 (IQR $9933 to $20 033) for those cared for in an outpatient neonatal withdrawal center. NICU admission was avoided in 78% of the population once both alternative locations were fully implemented. CONCLUSIONS: In this cohort of infants, a 219% increase in the number of infants treated for NAS overwhelmed the capacity of our traditional resources. There was a need to develop new treatment approaches dealing with the NAS crisis and a growing population of prenatally exposed babies. We found that the described model of care significantly reduced charges and stabilized admissions to our NICU despite the marked increase in cases. Without this system, our NICU would be in a critical state of gridlock and diversion; instead, we have efficient management of a large NAS population.

Short term cost of care for the surviving periviable neonate.

OBJECTIVE: To determine the hospital cost and distribution of financial charges for the initial hospitalization of the surviving periviable neonate. STUDY DESIGN: In this retrospective case series, we analyzed medical records and financial data for neonates 23-25 weeks' gestational age in a single tertiary care NICU over 42 months. A detailed breakdown of hospital cost components and charges was determined for all survivors during their initial hospitalization. Statistical significance was determined using the Bonferroni-Sidak method. RESULTS: Overall survival was 78% in infants born at 23-25 weeks' gestational age. Survival increased and length of stay and hospital costs decreased with increased gestational age (p < 0.05 for all). Hospital charges were distributed as: NICU 56%, respiratory 11%, pharmacy 6%, laboratory 6%, radiology 6%, surgery 1%, neonatology 13% and miscellaneous 1%. CONCLUSION: Our study describes the hospital cost and distribution of charges for the periviable neonate during the initial hospitalization. These economic data may guide clinicians in quality improvement and cost management.

Post-resuscitation complications in term neonates.

OBJECTIVE: It has been recommended that all newborn babies who have received substantial resuscitation be cared for in an environment where post-resuscitation care can be provided. To test this recommendation, we examined whether infants who received delivery room resuscitation and seemingly recovered by 5 min age are at increased risk of short-term morbidity. STUDY DESIGN: We undertook a retrospective analysis of the outcomes of babies who received delivery room resuscitation, and who had seemingly recovered by 5 min age, over a 1 year time period at a single academic institution. The 33 babies were compared with outcomes of 33 controls who received no resuscitation with normal 1 and 5 min Apgar scores. Complication rates and admissions to the neonatal intensive care unit (NICU) were compared between the two groups using the chi2 test. RESULTS: Fifty-two percent of the study group and three percent of the control group were admitted to the NICU (P<0.01). Short-term complications were noted in 61% of the study group and three percent of the control group (P<0.01). CONCLUSION: Increased short-term morbidity is demonstrated in neonates who receive delivery room resuscitation and are seemingly recovered at 5 min, when compared to a group of infants with normal Apgar scores at one and 5 min; and these infants should be cared for in an environment where ongoing evaluation can be provided.

Intrauterine herpes simplex virus infections.

Neonatal herpes simplex virus (HSV) infection is usually acquired at birth, although a few infants have had findings suggestive of intrauterine infection. We describe 13 babies who had clinical manifestations of intrauterine HSV infection, including skin lesions and scars at birth (12), chorioretinitis (eight), microcephaly (seven), hydranencephaly (five), and microphthalmia (two). All infants had combinations of these defects. Infection was proved by viral isolation in each case; all isolates were HSV-2. Two infants died during the first week of life; 10 of the surviving infants had severe neurologic sequelae, and one infant was blind. Four mothers experienced an apparent primary genital HSV infection, and one had recurrent infection, at varying times during gestation. The remaining women denied a history of symptoms of genital HSV infection. These findings indicate that intrauterine HSV infection can occur as a consequence of either primary or recurrent maternal infection and has severe consequences for the fetus.

Fatal coxsackievirus B4 infection in a neonate.

We reported a fatal coxsackievirus B4 infection in a neonate. The CSF WBC was elevated, with polymorphonuclear leukocytes predominating initially and lymphocytes predominating later in the illness. Autopsy findings included inflammation of the heart and liver. Coxsackievirus B4 was isolated from the heart and quantitated as 10(3) 50% tissue culture infectious doses (TCID50) per gram of myocardium.

Respiratory system impedance from 4 to 40 Hz in paralyzed intubated infants with respiratory disease.

To describe the mechanical characteristics of the respiratory system in intubated neonates with respiratory disease, we measured impedance and resistance in six paralyzed intubated infants with respiratory distress syndrome, three of whom also had pulmonary interstitial emphysema. We subtracted the effects of the endotracheal tube after showing that such subtraction was valid. Oscillatory flow was generated from 4 to 40 Hz by a loudspeaker, airway pressure was measured, and flow was calculated from pressure changes in an airtight enclosure mounted behind the flow source (speaker plethysmograph). After subtraction of the endotracheal tube contribution, resistance ranged from 22 to 34 cmH2O liter-1 s; compliance from 0.22 to 0.68 ml/cmH2O; and inertance from 0.0056 to 0.047 cmH2O liter-1 s2. Our results indicate that, for these intubated infants, the mechanics of the respiratory system are well described as resistance, compliance, and inertance in series. Most of the inertance, some of the resistance, and little of the compliance are due to the endotracheal tube. When the contribution of the endotracheal tube is subtracted, the results are descriptive of the subglottal respiratory system. These data characterize the neonatal respiratory system of infants with respiratory distress syndrome (with or without pulmonary interstitial emphysema) in the range of frequencies used during high frequency ventilation.

Surfactant dysfunction in diabetic offspring: inhibitors and fatty acid lecithin content.

We have previously demonstrated that the lungs of fetuses of alloxan-diabetic rabbits are functionally immature when compared with controls. In this study we have examined pulmonary lavage fluid from fetuses of diabetic and control does for the presence of a surfactant inhibitor, cholesterol content, and phosphatidylcholine (lecithin) fatty acid content. When lavage fluids from fetuses of control and diabetic does were mixed and examined on the surface balance, the measured surfactant content corresponded to the arithmetic average of the surfactant content of the individual fluids, thus ruling out the presence of an excess of a surfactant inhibitor. We were able to demonstrate inhibition of surfactant function when exogenous cholesterol was added to lavage samples, but cholesterol content of lavage fluid from fetuses of diabetic and control does was not significantly different. Finally, the fatty acid composition of surfactant phosphatidylcholine was not different between the two groups. These studies indicate that mechanisms other than the presence of a surfactant inhibitor or altered fatty acid composition must explain the functional immaturity seen in offspring of the diabetic pregnancy.

High-frequency ventilation in premature infants with lung disease: adequate gas exchange at low tracheal pressure.

The technique of high-frequency ventilation (HFV) was used in ten infants with severe respiratory distress syndrome and five infants with pulmonary interstitial emphysema (PIE). The mean frequency used was 12 Hz (720/min). Peak tracheal pressure for the infants with respiratory distress syndrome was 28 +/- 4 (SD) cm H2O on conventional ventilation, and 22 +/- 4 cm H2O on HFV (P less than .05). For the infants with PIE, peak tracheal pressure decreased from 38 +/- 11 to 24 +/- 5 cm H2O (P less than .05). Mean tracheal pressure was the same for the two types of ventilation. No adverse clinical or pathologic side effects were seen. Clinical and radiologic improvements were seen in the infants with PIE after initiation of HFV. It is believed that these improvements in the patients with PIE were secondary to the decrease in tracheal pressure and that HFV may have a role in treatment of preexisting barotrauma and its prevention. These studies contribute to the preliminary data necessary before controlled trials of HFV in infants with respiratory distress syndrome and PIE can be carried out.

Apnea monitoring by acoustic detection of airflow.

An acoustic monitor to detect apnea in infants has been developed. Recordings of a signal derived from breath sounds at the nose were made in eight premature infants and compared with observation of the infant and with transthoracic impedance and ECG monitoring. The acoustic monitor detected 26 episodes of apnea lasting 15 seconds or longer which were confirmed by observation and by heart rate slowing of at least 20 beats per minute. Only seven of these episodes were detected by the impedance monitor. The ECG monitor alarmed during the nine spells in which heart rate dropped below 100 beats per minute, 27.5 +/- 9.7 seconds after breath sounds ceased. Inasmuch as the acoustic device detects absent airflow during central or obstructive apnea before bradycardia occurs and is insensitive to body movements, it represents an improved monitoring technique for infants with apnea.

Sudden infant death syndrome in infants with bronchopulmonary dysplasia.

The association between bronchopulmonary dysplasia and sudden infant death syndrome was studied retrospectively in low-birth-weight infants discharged from the neonatal program at Harvard Medical School. The incidence of sudden infant death syndrome was seven times greater in infants with bronchopulmonary dysplasia when compared with a group of control infants without bronchopulmonary dysplasia. Confounding factors, including birth weight, sex, multiple birth, socioeconomic status, and apnea were evaluated. The results indicate that there is an association between bronchopulmonary dysplasia and sudden infant death syndrome.

Upper thoracic extralobar pulmonary sequestration presenting with respiratory distress in a newborn.

An upper thoracic extralobar pulmonary sequestration in a newborn is presented. It was present on the initial chest radiograph taken because of respiratory distress. The sequestration was surgically removed and the infant's respiratory difficulties improved.