Bacterial meningitis. Effect of antibiotic treatment on cerebrospinal fluid.

The effects of full short-term antibiotic treatment on cerebrospinal fluid (CSF) findings were studied retrospectively in 68 children with acute bacterial meningitis. The features of CSF at admission were compared with those of the CSF obtained after 44-68 hours of therapy. Except in one case with H. influenzae and one case with pneumococcal meningitis, all CSF cultures were negative in the repeat specimen. In three of 16 children with meningococcal meningitis, the CSF glucose levels became normal in the second specimen. In all remaining 65 children, however, full intravenous antibiotic treatment for 44-68 hours did not alter the biochemistry and cytology of the CSF, which retained its "bacterial" character. From these findings it may be discerned that partial antibiotic treatment is even less likely to distort a 'bacterial' CSF.

Prenatal diagnosis of liver calcifications.

OBJECTIVE: To report our experience with the prenatal diagnosis of hepatic calcification. METHODS: Routine ultrasonography was done in 24,600 consecutive pregnancies of 14-26 weeks' gestation. Detailed sonographic studies, amniocenteses, and chromosomal, bacteriologic, virologic, and serologic investigations were performed in each case with calcifications. RESULTS: Hepatic calcifications were diagnosed in 14 fetuses--an incidence of one in 1750--at gestational ages of 15-26 weeks. Twelve fetuses had one or two calcified foci, one fetus had four scattered foci, and one had diffuse calcification of the liver as well as peritoneal and intestinal calcifications. Three fetuses (21%) had associated severe malformations: two with trisomy 18 and one with dwarfism and hydronephrosis; these fetuses were aborted. One fetus with polyhydramnios and calcifications within the bowel died in utero; an autopsy was not allowed, but the external examination was normal. No case had serologic evidence of recent infection with Toxoplasma, rubella virus, cytomegalovirus, herpes simplex virus, or syphilis. Amniotic fluid (and neonatal urine where applicable) cultures for cytomegalovirus were negative. Ten fetuses were normal at birth, and nine of them were followed-up for a period of 4 months to 4.5 years. All were found to be healthy and thriving children. CONCLUSION: Our experience indicates that fetal hepatic calcification is not a rare ultrasonographic finding, and each fetus with such calcifications should be thoroughly evaluated for malformations, chromosomal anomalies, and viral infection. If the work-up is negative, subsequent neonatal outcome carries a good prognosis.

Persistent intrahepatic right umbilical vein in the fetus: a benign anatomic variant.

OBJECTIVE: To evaluate outcomes of fetuses with antepartum sonographic diagnoses of persistent intrahepatic right umbilical veins. METHODS: A detailed fetal sonographic examination was done in 30,240 consecutive pregnancies at 14-26 weeks' gestation. High- and low-risk pregnancies were included and persistent right umbilical veins specifically were recorded. RESULTS: Sixty-nine fetuses had persistent intrahepatic right umbilical veins, of which 60 had no additional sonographic abnormalities, four had transient nuchal findings, and four had minor anomalies or anatomic variants. Only one of the 69 fetuses had a major anomaly (diaphragmatic hernia), and died after surgery. The remaining 68 fetuses were normal and healthy after birth. CONCLUSION: Persistent intrahepatic right umbilical vein is a fetal anatomic variant that is not rare and usually associated with a favorable outcome.

Early postnatal dexamethasone treatment and increased incidence of cerebral palsy.

OBJECTIVE: To study the long term neurodevelopmental outcome of children who participated in a randomised, double blind, placebo controlled study of early postnatal dexamethasone treatment for prevention of chronic lung disease. METHODS: The original study compared a three day course of dexamethasone (n = 132) with a saline placebo (n = 116) administered from before 12 hours of age in preterm infants, who were ventilated for respiratory distress syndrome and had received surfactant treatment. Dexamethasone treatment was associated with an increased incidence of hypertension, hyperglycaemia, and gastrointestinal haemorrhage and no reduction in either the incidence or severity of chronic lung disease or mortality. A total of 195 infants survived to discharge and five died later. Follow up data were obtained on 159 of 190 survivors at a mean (SD) age of 53 (18) months. RESULTS: No differences were found between the groups in terms of perinatal or neonatal course, antenatal steroid administration, severity of initial disease, or major neonatal morbidity. Dexamethasone treated children had a significantly higher incidence of cerebral palsy than those receiving placebo (39/80 (49%) v. 12/79 (15%) respectively; odds ratio (OR) 4.62, 95% confidence interval (95% CI) 2.38 to 8.98). The most common form of cerebral palsy was spastic diplegia (incidence 22/80 (28%) v. 5/79 (6%) in dexamethasone and placebo treated infants respectively; OR 4.45, 95% CI 1.95 to 10.15). Developmental delay was significantly more common in the dexamethasone treated group (44/80 (55%)) than in the placebo treated group (23/79 (29%); OR 2. 87, 95% CI 1.53 to 5.38). Dexamethasone treated infants had more periventricular leucomalacia and less intraventricular haemorrhage in the neonatal period than those in the placebo group, although these differences were not statistically significant. Eleven children with cerebral palsy had normal ultrasound scans in the neonatal period; all 11 had received dexamethasone. Logistic regression analysis showed both periventricular leucomalacia and drug assignment to dexamethasone to be highly significant predictors of abnormal neurological outcome. CONCLUSIONS: A three day course of dexamethasone administered shortly after birth in preterm infants with respiratory distress syndrome is associated with a significantly increased incidence of cerebral palsy and developmental delay.

Failure of early postnatal dexamethasone to prevent chronic lung disease in infants with respiratory distress syndrome.

OBJECTIVE: To study the effect of early postnatal dexamethasone (days 1-3) on the incidence and severity of chronic lung disease in preterm infants with respiratory distress syndrome. METHODS: A multicentre, randomised, placebo controlled, blinded study was carried out in 18 neonatal intensive care units in Israel. The primary outcome measure was survival to discharge without requirement for supplemental oxygen therapy beyond 28 days of life. The secondary outcome measures were requirement for mechanical ventilation at 3 and 7 days, duration of ventilation or oxygen therapy, need for subsequent steroids for established chronic lung disease and incidence of major morbidities. RESULTS: The study consisted of 248 infants (dexamethasone n = 132; placebo n = 116). No differences were found in the outcome variables except for a reduction in requirement for mechanical ventilation at age 3 days in treated infants (dexamethasone 44%, placebo 67%; P = 0.001). Gastrointestinal haemorrhage, hypertension, and hyperglycaemia were more common in treated infants, but no life threatening complications, such as gastrointestinal perforation, were encountered. CONCLUSIONS: These data do no support the routine use of early postnatal steroids, but may justify further study in a selected, high risk group of infants.

Critical ages in brainstem development revealed by neonatal 3-channel Lissajous' trajectory of auditory brainstem evoked potentials.

Auditory brainstem evoked potentials (ABEPs) were recorded from 91 newborns from 7 age groups between 26 to 43 weeks of gestation. In addition to the widely used vertex-mastoid derivation, potentials were recorded from three orthogonal electrode configurations, and represented in 3 dimensional voltage-space as three-channel Lissajous' trajectories (3CLTs). ABEPs were evoked by alternating polarity, monaural 75 dBnHL clicks presented at rates of 10/s, 55/s and 80/s. Potentials were also recorded to 45 dBnHL and 15 dBnHL clicks presented at 10/s. 3CLT point by point (apex latencies, amplitudes and orientation) as well as planar segment (planar segment position and duration) descriptors, along with peak latencies of the vertex-mastoid peaks, were followed for effects of age, stimulus intensity and rate. ABEPs began to appear consistently at 29 weeks of gestation to high stimulus intensities, with a rapid decrease of ABEP thresholds up to 34 weeks. At 35 weeks, thresholds stabilized approximately at adult values. The results indicate a significant effect of stimulus rate and intensity as well as of gestational age group on apex latencies. The findings also showed changes in apex orientations associated with stimulus rate and intensity interacting with gestational age. 3CLT descriptors enhanced the understanding of these results in relation to developmental and maturational aspects of the auditory system. The results may be explained by maturational change in relative contributions of constituents of the complex ABEP generators.

Intra- and extra-uterine development of neonatal 3-channel Lissajous' trajectory of auditory brainstem evoked potentials.

This study compared intra- and extra-uterine maturation of the auditory pathway, using auditory brainstem evoked potentials (ABEPs), recorded with three orthogonal differential electrode configurations. From the three records of each subject, 3-channel Lissajous' trajectories (3CLTs) were derived and analyzed. 107 newborns were compared at the same gestational and post-conceptional (gestational+postnatal) age, from 29 weeks (wks) up to 43 wks. In addition, we explored the effects and neurophysiological consequences of early exposure to extra-uterine life, on the peripheral and central portions of the auditory pathway. Our findings indicate that exposure of premature infants to the extra-uterine environment is associated with advanced peripheral development, but slower central conduction compared to intra-uterine development.

Development of auditory brainstem evoked potentials in newborn infants: a three-channel Lissajous' trajectory study.

Auditory brainstem evoked potentials (ABEP) were recorded from 50 newborns (35-43 weeks gestational age), using three orthogonal differential electrode pairs, in addition to the widely used vertex-mastoid derivation. Potentials were evoked by alternating polarity, 75 dBnHL clicks presented monaurally at a rate of 10/s. From the records of the three orthogonal electrode pairs (nasion-inion; vertex-spinous cervical process VII; left-right mastoids), Three-channel Lissajous' trajectories (3CLT) were derived and analyzed. 3CLT point-by-point, as well as segmental descriptors were compared with peak latencies of the vertex-mastoid derivation. Point-by-point 3CLT descriptors included apex amplitude, latency and orientation. Segmental descriptors included planar segment beginning latencies, duration and orientation. The interpretation of these results in relation to developmental aspects of the auditory system, as well as to the question of ABEP generators, is enhanced by using 3CLT descriptors of ABEP, which are more comprehensive than their single-channel counterparts. 3CLT apices correlated well with the Vertex-Mastoid defined peaks. Both peak and apex latency changes indicate that at the developmental stages surveyed in this study, development takes place in the more central portions of the pathway, whereas the peripheral portion is already relatively mature. The results also indicate a maturational change in the relative contributions of constituent generators of ABEP components.

Survival and long-term outcome of infants delivered at 24 to 28 weeks' gestation, by method of delivery and fetal presentation.

Significant advances in perinatal intensive care and the increased chances of neonatal survival that have evolved in the last decade have posed moral and medicolegal questions for obstetricians that are as yet unanswered. Aggressive delivery management and major interventions for infants who were not long ago considered to be nonviable have become increasingly common. On the other hand, reports of high incidence of handicaps in the survivors cause great concern and add to the dilemma facing obstetricians. In this study, survival and long-term morbidity in 169 infants delivered at 24 to 28 weeks' gestation have been analyzed according to method of delivery and fetal presentation. At 24 to 25 weeks, survival was extremely low (10.5%) while major handicap rate was very high (42.9%). Infants born at 26 to 28 weeks' gestation had a considerably higher survival potential (42% to 74%), with an incidence of major handicap of less than 10%. At 26 to 28 weeks, abdominal delivery did not alter survival prospects of vertex-presenting infants; however, it improved survival of breech-presenting infants (70.0% compared with 22.2%) and showed a trend toward a lower handicap rate in the survivors.

Branched-chain amino acids and respiratory pattern and function in the neonate.

Branched-chain amino acids (BCAA) increase respiratory drive in adults and improve diaphragmatic function in vitro. This study was designed to examine the effects of increased amounts of BCAA in intravenous nutrition on respiratory function and episodes of apnea in premature infants. An open cross-over design was used, with each patient serving as his own control. Ten premature infants, 34 weeks' gestation or less, were observed. Mean gestational age was 30.6 weeks (range 27 to 33 weeks), mean birth weight was 1487 gm +/- 300 gm, and the age at study was 5 to 33 days. For three consecutive 24-hour periods, the infants received routine total parenteral nutrition (TPN) (30% BCAA), enriched TPN (53% BCAA), and routine TPN (30% BCAA). Pulmonary function, apnea frequency, blood chemistry, and amino acid pattern were measured. Enriched TPN resulted in significant increases in all infants in dynamic compliance, from 2.41 +/- 1.07 to 4.55 +/- 2.78 ml/cm H2O (p < 0.025), and in specific dynamic compliance from 1.67 +/- 0.64 to 3.1 +/- 1.51 ml/cm H2O/kg (p < 0.005). Total pulmonary resistance decreased from 40.3 +/- 23.3 to 24.0 +/- 20.9 cm H2O/L/sec (p < 0.05), and peak-to-peak pressure decreased from 5.96 +/- 0.93 to 4.09 +/- 2.34 cm H2O (p < 0.05). All values returned to baseline with resumption of the routine TPN. In four infants with significant apnea, the average number of episodes of apnea decreased from 58 during standard TPN to 11 with the enriched solution infusion during matched 12-hour periods (p < 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)

The use of calcium gluconate prior to verapamil in infants with paroxysmal supraventricular tachycardia.

Verapamil is a useful drug for treating supraventricular tachycardia; however, severe side effects occasionally have been reported in infants. We describe here our experience with the use of a 10 percent solution of intravenous calcium gluconate prior to the use of verapamil in infants with paroxysmal supraventricular tachycardia. In all the attacks verapamil converted the supraventricular tachycardia to sinus rhythm. We feel that calcium gluconate injected previous to verapamil can avoid the negative inotropic effects without interfering with the antiarrhythmic properties of verapamil.

Survival and long-term morbidity in preterm infants with and without a clinical diagnosis of periventricular, intraventricular hemorrhage.

The prognosis of clinically diagnosed periventricular, intraventricular hemorrhage on the survival and long-term outcome of 169 infants delivered at 24 to 30 weeks gestation who survived more than 48 hours was evaluated. Periventricular, intraventricular hemorrhage was confirmed by ultrasound in 37.9% of the survivors. In this group the survival rate was 64% and the major handicap rate was 14.6%. In contrast, the survival of infants who did not have a clinical diagnosis of periventricular, intraventricular hemorrhage was greater than 90% with a major handicap rate of only 3.2% (P < 0.0001 and P < 0.03, respectively). Infants with clinical diagnosis of periventricular, intraventricular hemorrhage who were found to have grades 1-2 by ultrasound had the same survival rate as those without a clinical diagnosis of periventricular, intraventricular hemorrhage (90.5%), while infants with grades 3-4 had a survival rate of only 51.2% (P < 0.01). We conclude, that preterm infants who survive longer than 48 hours and do not have a clinical suspicion of periventricular, intraventricular hemorrhage, have an excellent prognosis. In these circumstances brain sonography can be deferred without jeopardizing the infants' health.

Intratracheal pulmonary ventilation in premature infants and children with intractable hypercapnia.

The feasibility of intratracheal pulmonary ventilation (ITPV) was tested in five ventilated moribund neonatal and pediatric patients with uncontrollable hypercapnia: a 2-year-old child, a 52-day-old infant, and three premature infants (29, 29, and 26 weeks gestation; 1300 g, 1100 g and 890 g birth weight, respectively). ITPV was applied for 9.5, 8, 25, 58.5, and 47.5 hr, respectively. An intratracheal catheter (Cook Critical Care, Inc., Bloomington, IN) with a reversed continuous flow of gas at its tip (away from the lungs) allowed flushing of CO2 from the proximal dead space. Marked reductions in Paco2, ranging from 37% to 71% and improvement in pH were achieved within 4-6 hr of applying ITPV. During ITPV, the mean lowest Paco2 was significantly less than the pre-ITPV Paco2 (p < 0.0017), and the mean best pH was significantly higher than the pre-ITPV pH (p < 0.015). In four patients, despite significant reductions in Paco2, there was no substantial improvement in their baseline condition (shock and severe metabolic acidosis or coma) and they were switched back to conventional ventilation. This led to worsening hypercapnia to pre-ITPV values. These four patients subsequently died. It is possible that these patients were already too ill to derive significant benefit from the technique. One premature infant survived, was successfully weaned to conventional ventilation and was eventually discharged home. ITPV can alleviate uncontrollable hypercapnia in ventilated neonatal and pediatric patients.

Recurrent nonimmune hydrops fetalis, A case report.

Nonimmune hydrops fetalis occurred in two pregnancies in one woman. The first fetus had the Wolff-Parkinson-White syndrome. In both pregnancies the mother had a skin rash and subfebrile temperature when the fetal anomaly was detected. No viral, bacterial or autoimmune cause was found.

The effects of caffeine on heart rate variability in newborns with apnea of prematurity.

OBJECTIVE: Apnea of prematurity is a common complication in premature newborns and caffeine is a widespread medication used to treat this complication. Caffeine may have adverse effects on the cardiovascular and central nervous system, yet its effects on the autonomic nervous system modulation of heart rate have not been studied in premature newborns, which was the objective of our study. STUDY DESIGN: We prospectively studied 21 premature newborns who were treated with caffeine. We analyzed heart rate variability by power spectral density and by dynamic nonlinear analyses methods. RESULT: There were no changes in heart rate, blood pressure or the autonomic nervous system tone following administration of caffeine, nor were the nonlinear dynamical properties of the system altered by caffeine. CONCLUSION: Caffeine does not have detrimental effects on heart rate variability, heart rate or blood pressure in conventional doses given to premature newborns.

Infantile spinal muscular atrophy (SMA) and multiple congenital bone fractures in sibs: a lethal new syndrome.

Acute infantile spinal muscular atrophy (SMA type I, Werdnig-Hoffmann disease) has generally been accepted as an autosomal recessive disorder. However, several investigators have noted a slightly increased male to female ratio. We describe here a family with two affected male sibs who had a form of acute infantile SMA with congenital bone fractures, whose parents were first cousins. Pedigree analysis strongly suggested autosomal recessive inheritance, but X linked recessive inheritance could not be ruled out. In view of the heterogeneity of the SMAs, and the distinct clinical features found in our patients, we suggest that their infantile SMA might well be a distinct entity. We suggest that SMA I with congenital contractures and bone fractures appears to be a recognisable disorder that can be distinguished from the more common classic form of SMA I.

Foreign body in the airway. A review of 200 cases.

Two hundred children aged 6 months to 12 years were admitted to the hospital with a foreign body in the airway. Food materials constituted 93% of all foreign bodies. A positive history of foreign body aspiration was obtained in 88% of the cases. The most common symptoms of laryngotracheal foreign bodies were dyspnea, cough, and stridor, whereas those of bronchial foreign bodies were cough, decreased air entry, wheezing, and dyspnea. Chest fluoroscopy contributed to the diagnosis in 90% of the cases of bronchial foreign bodies, but only 32% of those in the laryngotracheal area. Of the foreign bodies removed, 98 1/2% were done by laryngoscopy, tracheoscopy, and/or bronchoscopy. Complications were involved in 6% of the cases, including one death. History of recurrent intractable pneumonia should make one consider a foreign body in the airway. Removal of one foreign body does not exclude the existence of another. The condition may be fatal; thus immediate removal of the foreign body is mandatory.

Isolated large fourth ventricle in early pregnancy--a possible benign transient phenomenon.

Twenty-one fetuses with an enlarged fourth ventricle were detected by ultrasound at 14-16 weeks' gestation. No other central nervous system anomalies were observed and a normal size fourth ventricle was noted in all cases on follow-up scans at 22-23 weeks' gestation. Five fetuses had associated structural anomalies: a single umbilical artery in two cases, non-septated cystic hygroma in two cases and ventricular septal defect in one fetus. All fetuses had a normal brain sonogram after delivery. Nineteen newborns who were followed up to the age of one year had no developmental problems. It is concluded that an isolated enlarged fourth ventricle might be a physiological variant in early fetal life.