Cerebrospinal fluid concentrations of aqueous procaine penicillin G in the neonate.

Simultaneous serum and CSF samples were obtained following the intramuscular administration of 50,000 units/kg of aqueous procaine penicillin G in 25 neonates. Penicillin activity was detected in the sera and CSF of all patients. Peak serum levels were noted at four hours (mean +/- SEM, 17.1 +/- 6.3 micrograms/ml). Peak CSF levels were noted at 12 hours (0.70 +/- 0.35 microgram/ml). The serum level at 24 hours was 2.1 +/- 0.98 microgram/ml (range, 0.2 to 5.8 micrograms/ml); the CSF level at 24 hours was 0.12 +/- 0.05 micrograms/ml (range, 0.03 to 0.27 microgram/ml). These results demonstrate that spirocheticidal levels (greater than or equal to 0.03 microgram/ml) are achieved for at least 24 hours in the CSF following the intramuscular administration of aqueous procaine penicillin G in neonates.

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.

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.

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.

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.

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.

Challenges in the NICU: questions or answers?

In the changing paradigm of medicine, the cost of health care has become the bellwether for effective health care delivery. Managed care and case management are proposed as the only methodology suitable for this new model. The concept of early discharge is advanced as appropriate care. A Neonatal Intensive Care Unit (NICU) associated with an academic health center is seen as more costly than an NICU in a nonacademic setting. Little data exists, however, that support or refute the above assertions. Measurement of relevant processes to determine the outcome of NICU care is essential to insure the delivery of quality health care within the cost-containment model.

Neonatal intensive care applications of near-infrared spectroscopy.

Near-infrared spectroscopy (NIRS) is a noninvasive technique for assessing cerebral hemodynamic variables and oxidative status in the neonatal intensive care setting. It can be performed for extended periods of time at the bedside without interfering with routine patient care. NIRS appears to have the ability to not only assess relative changes in oxygenated and deoxygenated hemoglobin, total hemoglobin, and cytochrome aa3, but it can also produce estimates of cerebral blood volume and cerebral blood flow. Research data document significant changes in these hemodynamic variables with patient activity and clinical interventions in both premature and term infants. NIRS may evolve into an important diagnostic and prognostic tool for neonatal neurologic outcome.

Fatal hepatoadrenal necrosis in the neonate associated with echovirus types 11 and 12 presenting as a surgical emergency.

Two neonates presented to our service with suspected intraabdominal surgical emergencies. Both subsequently were found to have hepatoadrenal necrosis due to overwhelming echoviral infection. Echovirus types 11 and 12 were isolated postmortem. The latter virus has not been associated previously with fulminant neonatal illness.

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.

Candida endophthalmitis: a manifestation of candidiasis in the neonate.

Candida endophthalmitis is a frequent complication of systemic candidiasis. The case reported emphasizes the usefulness of indirect ophthalmoscopy in evaluating infants suspected of having disseminated candidal infection and describes the pathologic findings of Candida endophthalmitis in the neonate.

Characterization of the cardiomyopathy in infants of diabetic mothers.

A transient form of hypertrophic cardiomyopathy has been previously described in infants of diabetic mothers (IDMs). The purpose of this study was to determine the incidence, natural history and pathologic features of this cardiomyopathy in symptomatic and asymptomatic IDMs. We studied 47 IDMs for evidence of cardiomyopathy. Among 24 symptomatic IDMs, five had marked septal hypertrophy with echocardiographic features suggesting left ventricular outflow obstruction and five had hypertrophy of the right ventricular free wall. With the exception of mild septal hypertrophy, these abnormalities resolved during the first 6 months of life, and echocardiograms in the first-degree family members were normal. Of 23 asymptomatic IDMs, three had septal hypertrophy and two had right ventricular free wall hypertrophy; none of the asymptomatic IDMs had evidence of outflow obstruction. One symptomatic IDM died, and autopsy revealed a hypertrophic septum that distorted both ventricular cavities. Microscopic examination revealed hypertrophic fibers and occasional areas of cellular disarray in the septum. Despite the clinical and pathologic similarities of the cardiomyopathy in IDMs to the hypertropic cardiomyopathies in older children and adults, its transient and nonfamilial nature suggest that it is a separate disease. We speculate that it is a manifestation of the generalized organomegaly in IDMs.