The use of indwelling radial artery catheters in neonates.

Indwelling radial artery catheterization was performed on 20 infants. In only one patient was it unsuccessful. Mean duration of indwelling catheterization was 44.1 hours. Advantages of this procedure include constant availability of arterial blood gas sampling and blood pressure monitoring. It is a relatively safe procedure offering a low incidence of clinical infection and serious vascular complications. Further experience will delineate its exact role in the care of the acutely ill neonate.

Bacterial colonization of radial artery catheters.

In 147 radial artery catheterizations performed, blanching or embolization was noted in 10.8% of the patients. Only a single episode of catheter-related septicemia was observed (0.6%) Mean duration of catheterization was 48 +/- 6 hours. Of 110 catheters cultured 25.4% grew bacteria; most organisms cultured were nonpathogenic. Duration of catheterization and intravascular infusion did not alter the incidence of catheter colonization.

Postnatal head shrinkage in small infants.

The front-occipital circumference, frontooccipital and biparietal diameters, degree of suture overriding and weight were measured daily during the first week of life in 50 infants of birth weight under 2,000 gm. In a second similar group of 21 infants, fronto-occipital circumference, weight, and sodium balance were measured daily during the first week of life. Head volumes were estimated from the circumference and diameters of the head. The parameters of head size and derived volumes changed maximally and significantly in the direction of intracranial shrinkage around 3 days of age. The degree of shrinkage was significantly correlated (P less than .005) with the degree of weight and cumulative sodium losses, and decreasing gestational age. We postulate that postnatal head shrinkage results from shift of sodium and water outward from the intracranial cavity as a transient phenomenon during the first week of life. The significance of head shrinkage is discussed.

Modern management of tetanus neonatorum.

Five infants with neonatal tetanus were managed with neuromuscular blockade and positive pressure ventilation. All survived. Tetanus was frequently confused with neonatal seizures at time of presentation. All infants were delivered at home. Mean age of onset of symptoms of poor suck, hypertonicity, and generalized spasms was 5.4 days with hospital admission at 6.4 days. Mean duration of mechanical ventilation was 34 days. Although hospital management of tetanus neonatorum may be expected to have a satisfactory outcome, it represents a costly and complex approach to a preventable disease.

Hypochloremic metabolic alkalosis following tolazoline-induced gastric hypersecretion.

Gastric hypersecretion following administration of tolazoline resulted in severe hypochloremic alkalosis in an infant with persistent fetal circulation. An initial bolus injection of 2 mg/kg was followed by an infusion of 5 mg/kg/hr for 24 hours. The infusion was then maintained at 2 mg/kg/hr for the next four days. Volume of gastric secretions exceeded 25 ml/kg/24 hr. Weaning from tolazoline and replacement of chloride and potassium corrected the metabolic alkalosis.

Hypercarbia at birth: a possible role in the pathogenesis of intraventricular hemorrhage.

To test the hypothesis that birth asphyxia has a role in the etiology of intraventricular hemorrhage (IVH), blood was collected from the umbilical artery (UA) at birth in 28 premature infants of 26 to 29 weeks gestation and analyzed for hydrogen ion concentration [H+], PCO2, standard bicarbonate level, and lactic acid level. The infants were followed up throughout their nursery stay until a diagnosis of IVH could be made or excluded, either by autopsy or clinical findings. Infants with IVH had lower Apgar scores. There were no differences in UA [H+] or bicarbonate or lactic acid levels. However, infants with IVH had a significantly higher UA PCO2. Although the difference appeared relatively small, the increase in PCO2 during labor may have been relatively large. It is concluded that hypercarbia, possibly by increasing cerebral blood flow, may be one important factor in the genesis of IVH.

Intraventricular hemorrhage and vitamin E in the very low-birth-weight infant: evidence for efficacy of early intramuscular vitamin E administration.

To determine whether early intramuscular vitamin E supplementation influences the incidence of intraventricular hemorrhage (IVH) in infants with birth weight less than or equal to 1,500 g, data were analyzed from 134 infants enrolled on a protocol to evaluate the efficacy of intramuscular plus oral vitamin E v oral supplementation alone in the treatment of retrolental fibroplasia. All 134 infants received, via nasogastric tube, 100 mg/kg/d of vitamin E daily (dl-alpha-tocopheryl acetate in MCT [medium-chain triglyceride] oil; 150 mosM) for at least 8 weeks with the first dose administered within the first eight hours of life. Sixty-four patients received, in addition, intramuscular vitamin E on days 1, 2, 4, and 6 of life and 70 patients received placebo injections in a randomized double-blind fashion. In the first week, vitamin E plasma levels were significantly higher in the 64 patients given intramuscular vitamin E. In spite of this difference no change in the incidence of sepsis or necrotizing enterocolitis was observed. Both the incidence and severity of intraventricular hemorrhage were reduced significantly in the patients given intramuscular vitamin E as compared to the patients given placebo (P = .013 and P = .04, respectively). The data suggest that vitamin E, a natural antioxidant, may play an important role in protecting the CNS microcirculation from the effects of hypoxic/ischemic injury.

Degenerative changes in neutrophils: an indicator of bacterial infection.

A review was made of 195 peripheral blood smears of 157 neonates who required sepsis work-up in the first month of life. Degenerative changes of neutrophils including vacuolization and toxic granulation were observed frequently in infants with culture-proven bacterial sepsis. Of 21 peripheral blood smears from 20 neonates subsequently proven to have bacterial infection, 17 had vacuolization present in the neutrophils for a sensitivity of 81%, a specificity of 93%, and a positive predictive accuracy of 59%. Toxic granulation changes in neutrophils showed similar results. This simple test can be performed easily in all hospitals; it does not require special laboratory facilities. The test appears to provide a valuable adjunct in the early detection of neonatal bacterial infection.

A prospective study of free bilirubin and other risk factors in the development of kernicterus in premature infants.

To assess the value of free bilirubin (FB) measurements in predicting kernicterus (KI) in sick premature infants, 91 newborns weighing less than 1,500 gm at birth were observed during the first week of like with twice daily FB and total bilirubin determinations. Autopsies were performed on 30 of the 53 infants who died. Seven had KI and 23 did not. There were no differences between infants with and with out KI in the maximum FB level (KI 18.2 +/- 4.5 [SEM] nm/liter, no KI 11.1 +/- 0.9 nm/liter, P not significant) or the total bilirubin level (KI 7.3 +/- 1.3 mg/100 ml, no KI 6.1 +/- 0.5 mg/100 ml, P not significant). In fact, three kernicteric infants had very low maximum FB levels (less than 10 nm/liter). These three infants had prolonged episodes of acidosis, hypoxemia, or hypothermia during the 24 hours preceding their maximum level of FB. Although elevated levels of FB may be predictive of KI in some infants, other factors may make the blood-brain barrier more permeable to low levels of FB. This may limit the clinical applicability of FB measurements.

The role of acidosis at birth in the development of hyaline membrane disease.

To test the hypothesis that intarpartum acidosis has a role in the etiology of hyaline membrane disease (HMD), blood was collected from the umbilical artery (UA) at birth from 110 premature infants and analyzed for hydrogen ion concentration ([H+]), PCO2, standard bicarbonate, and lactic acid. The infants were followed until a definite diagnosis was made of HMD (33 infants), type II respiratory distress syndrome (16 infants) or the absence of respiratory distress (61 infants). In general, infants with HMD were more premature and had lower Apgar scores than nondistressed infants; however, there were no significant differences between the two groups in any acid-base measurement. Only in those patients of 32 to 37 weeks' gestational age was it possible to detect a significant increase in UA [H+] in infants with HMD compared to those without respiratory distress. There was evidence that the reduced Apgar score of infants with HMD may be due to immaturity and abnormal pulmonary function secondary to lung disease. It is concluded that acidosis at birth is not a factor in the development of HMD except possibly in more mature infants.

Retrolental fibroplasia: further clinical evidence and ultrastructural support for efficacy of vitamin E in the preterm infant.

To further evaluate the efficacy of oral vitamin E in preventing the development of severe retrolental fibroplasia (RLF) in very low-birth-weight infants, 100 infants treated with 100 mg/kg/d of vitamin E (dl-alpha-tocopheryl acetate) were compared with 75 infants treated with 5 mg/kg/d of vitamin E (dl-alpha-tocopherol) in the same nursery during the previous year. All 175 infants weighed less than or equal to 1,500 g at birth and required supplemental oxygen. A total of 120 infants (69 treatment; 51 control) survived greater than or equal to 10 weeks. Multivariate analysis of the control population identified five risk factors (P less than or equal to .10): gestational age, level and duration of oxygen administration, intraventricular hemorrhage, sepsis, and birth weight. When multivariate analysis was applied to both control and treatment groups, the severity of RLF was found to be significantly reduced in infants given the treatment dose of vitamin E (P = .003). Ultrastructural analyses of 58 pairs of whole-eye donations from high-risk infants surviving less than 10 weeks suggest that the initial morphologic event is gap junction increases between the plasma membranes of adjacent spindle cells of the van-guard retina. Such extensively gap junction-linked spindle cells are apparently removed from the vasoformative process as early as 4 days of life, forming a barrier to further normal vascular development and triggering retinal and vitreal neovascularizations approximately 8 weeks later. These events are maximally suppressed by elevated plasma vitamin E levels in infants greater than or equal to 27 weeks gestational age.

Retrolental fibroplasia and vitamin E in the preterm infant--comparison of oral versus intramuscular:oral administration.

To evaluate the efficacy of four early intramuscular injections of vitamin E given in addition to continuous minimal oral vitamin E supplementation, 168 very low-birth-weight infants (less than or equal to 1,500 g) have enrolled in a randomized, double-masked, clinical study. All infants received vitamin E orally, 100 mg/kg/d. In addition, on days 1, 2, 4, and 6, seventy-nine infants received vitamin E intramuscularly, 15, 10, 10, and 10 mg/kg, respectively. On the same days, 89 control infants received placebo intramuscular injections. Multivariate analysis of the 135 infants who survived greater than or equal to 10 weeks showed no significant difference in the development of severe retrolental fibroplasia between these two supplementation schedules (P = .86). Plasma vitamin E levels never exceeded a mean of 3.3 mg/100 mL, and no toxicity was observed. Ultrastructural analyses of seven pairs of whole eye donations from infants receiving IM vitamin E demonstrated identical kinetics of gap junction formation between adjacent spindle cells as compared with 13 pairs of whole eye donations from control infants (P greater than .3). Therefore, oral vitamin E supplementation affords retinal protection against the development of severe retrolental fibroplasia when initiated on the first day of life and maintained continuously until retinal vascularization is complete.

Early detection of bacteremia in an outpatient clinic.

A total of 570 patients, aged less than 24 months, who were seen in the emergency room at Texas Children's Hospital for evaluation of acute febrile illness had a WBC count, differential count, and a blood culture obtained. Bacteremia occurred in 7.7% (n = 44) (22 Haemophilus influenzae; 17 Streptococcus pneumoniae; three Escherichia coli; one group B Streptococcus; one Staphylococcus aureus). The sensitivity, specificity, and positive predictive value of morphologic changes (vacuolization and toxic granulation) of polymorphonuclear neutrophils (segmented neutrophils plus band cells), WBC count greater than or equal to 15,000/microL and band cells greater than or equal to 500/microL were examined. Additionally, abnormalities in three of four tests (WBC count greater than or equal to 15,000/microL, band cells greater than or equal to 500/microL, segmented neutrophils greater than or equal to 10,000/microL, and/or total polymorphonuclear neutrophils greater than or equal to 10,500/microL) were evaluated. Morphologic changes of polymorphonuclear neutrophils were noted frequently in patients with culture-proven bacteremia (63% and 51% positive predictive value for vacuolization and toxic granulation, respectively) and were more predictive of bacterial infection than traditional tests. If both vacuolization and toxic granulation were present, the positive predictive value increased to 76%. Examination of the peripheral blood smear may provide important adjunctive information for the presence of bacteremia prior to bacteriologic confirmation.

Nevus cell aggregates in the placenta. A histochemical and electron microscopic study.

This is a report of the histochemical and ultrastructural analysis of nevus cell aggregates in the placenta from a neonate with a giant pigmented nevus. Although the distinction between aberrant migration of neural crest elements and blood-borne metastasis from the giant pigmented nevus is not readily resolved, the authors favor the former as an explanation of this unusual placental lesion.

Development of beta-adrenergic control of phospholipid secretion in rabbit lung.

Lung distension is associated with increased phospholipid secretion into the air spaces. Basal, lavage-induced, and inflation-produced phospholipid secretion, in postmortem in situ lungs of newborn rabbits, were examined at three different levels of maturity, with and without 10(-3) M dl-propranolol. Lungs were lavaged with saline at successive 3- and 15-min time intervals to separate basal from lavage-induced secretion. Inflation-produced secretion was studied after static inflation at 30 cmH2O for 30 min. At 27.5 days gestation, basal secretion was undetectable, and neither lavage-induced nor inflation-produced secretion were influenced by propranolol. At 29.5 days gestation, basal secretion was only just detectable. Distension-associated secretion was increased over that present at 27.5 days gestation, and propranolol had a significant inhibitory effect, especially on lavage-induced secretion, in which the inhibition was shown to be rapidly reversible. There was a significant increase of basal secretion at 2.5 days postterm, possibly inhibited by propranolol. In addition, there was a further substantial increase of distension-associated secretion, and the inhibitory effect of propranolol persisted. These changes were independent of the sedimentation behavior of lavaged phospholipid. Overall, the results are consistent with evidence, produced in other laboratories, that there is an increasing density of sympathetic neurons and beta-adrenergic receptors in whole lung preparations during late gestation in the rabbit and suggest that granular pneumocytes, the presumed source of secreted phospholipid, take part in this developmental change.

Hyaline membrane disease and acidosis at birth in twins.

To test the hypothesis that the increased incidence of hyaline membrane disease in second-born twins is related to acidosis at birth, umbilical arterial [H+] was measured in 26 sets of premature twins. Although overall Twin B had a lower Apgar score than Twin A, there was no difference in their [H+]. If the delivery interval was prolonged over 8 minutes then Twin B infants were more acidemic and had lower Apgar scores. Infants with hyaline membrane disease had lower Apgar scores, but were not more acidemic than infants without respiratory distress. Our data suggest that acidosis at birth is not an important factor in the development of hyaline membrane disease.

Calcification of superficial scalp veins secondary to intravenous infusion of sodium bicarbonate and calcium chloride.

Soft tissue calcification has been reported following the intramuscular injection of calcium salts and the intravenous administration of calcium gluconate. The present case report describes a neonate in whom calcification of the superficial scalp veins developed following administration of calcium chloride and sodium bicarbonate through a scalp vein needle.

Examination of the anterior vascular capsule of the lens: III. Abnormalities in infants with congenital infection.

The disappearance of the anterior vascular capsule of the lens (tunica vasculosa lentis) in the preterm infant has been established to be useful in accurately estimating gestational age between the twenty-seventh and thirty-fourth weeks in infants appropriate or small for gestational age. Six infants have been studied with abnormalities of the anterior vascular capsule of the lens in which congenital TORCH infection has been documented (1 toxoplasmosis, 2 rubella, 2 cytomegalovirus, and 1 herpes simplex virus). Since the anterior vascular capsule generally atrophies symmetrically and completely after the thirty-fourth week of gestation, the findings of marked asymmetry and/or persistence and hypertrophy of the anterior vascular capsule of the lens warrants initiation of TORCH studies in the newborn infant.

Examination of the anterior vascular capsule of the lens: II. Assessment of gestational age in infants small for gestational age.

Between the twenty-seventh and thirty-fourth weeks of gestation, the appearance of the anterior vascular capsule of the lens (tunica vasculosa lentis) has been established to be useful in accurately estimating gestational age. Thirty-three infants assessed by maternal dates and Dubowitz scoring were studied with the direct ophthalmoscope following dilatation of the pupil in the first 24 hours of life. Five discordant twins, eight concordant twins, and twenty singletons were determined to be markedly small for gestational age on the basis of birth weight (less than tenth percentile). As in infants who are appropriately sized for dates, the disappearance of the anterior vascular capsule of the lens in infants who are small for dates correlates well with their gestational age and is reliable for gestational age assessment (p less than 0.0005).

Colobomatous microphthalmia, heart disease, hearing loss, and mental retardation--a syndrome.

A syndrome consisting of colobomatous microphthalmia, heart disease, abnormalities of the external ear with associated hearing loss, and mental retardation is described. Nine children and one adult were evaluated. There is not race or sex predilection. The syndrome can be heritable, as shown by a mother and daughter who were among the patients. In addition to the four major components enumerated, multiple other anomalies may be associated. In some cases, the syndrome may occur incompletely. Whenever two or more of the four components are recognized, the other systems usually affected should be investigated.