Neonatal thermography.

Anterior and posterior view thermograms were recorded in 37 neonates. Studies were performed under a radiant heater servocontrolled to an abdominal skin temperature of 36.0 C. Heart, liver, and kidneys, being highly vascular structures, were detected as "warm" areas on the body surface. A longitudinal study of an infant with a patent ductus arteriosus and congestive heart failure deomnstrated a generally cooler chest following a decrease in pulmonary artery blood flow accomplished by ductal ligation. Another infant demonstrated a unilateral warm area posteriorly over the left flank. At autopsy the right kidney and its vasculature internal organs. Thermography may prove to be a simple noninvasive tool for routine screening in the neonate of highly vascular internal organs. Thermographic detection of renal malformation may offer considerable potential.

Differentiating environmental from disease-related fevers in the term newborn.

It is often difficult to differentiate environmental overheating from disease-related fever in the newborn. The purpose of this study was to establish the normal relationship between peripheral skin temperature and rectal temperature in normal newborn infants whose rectal temperatures were in the upper range of normal (99.0 to 99.6 F) and to compare it with that relationship in infants with fevers known to be disease related. Seventy-eight paired rectal and anterior mid-lower leg skin temperatures were obtained from 41 normal 2-day-old infants. Thirteen similar paired temperatures were measured in 13 full-term infants admitted from home with fever (greater than 100.0 F). The rectal temperature-leg temperature (RT-LT) difference in the normal infants ranged between -1 and +4 F, with a mean of +1.14 F, whereas in the febrile infants it ranged between +5.7 and 12.9 F with a mean of 7.90 F. In febrile infants there was no trend in RT-LT difference as rectal temperatures rose whereas normal infants showed a tendency toward a decreasing RT-LT difference with increasing temperatures. When an RT-LT difference of +3 F is chosen as an arbitrary boundary between environmentally overheated infants and infants with disease-related fevers, it is estimated that 0.5% of infants with disease-related fevers would be incorrectly classified. The RT-LT difference adds an objective guideline for evaluation of temperature elevation in the full-term, appropriate for gestational age neonate.

Lidocaine intoxication in a newborn following local anesthesia for episiotomy.

A case report of lidocaine intoxication in a newborn following local anesthesia for maternal episiotomy is presented. A molded head in the occiput posterior position may predispose to inadvertent, direct injection of the fetal scalp.

Alternative to diagnosis-related groups for newborn intensive care.

Clinical and billing data were collected on all admissions to six California newborn intensive care units during a 6-month period. Charges were adjusted to costs using Medicaid cost to charge ratios and for inflation, and patients were classified by the diagnosis-related group (DRG) system. Costs were from 97% to 708% more than the proposed DRG reimbursement levels. Regression analysis showed that DRGs explained 22% of the variation in costs. An alternative model using binary variables to control for birth weight, assisted ventilation, surgery, survival, multiple births, and mode of discharge explained 42% of the variation in costs. In contrast to other proposed DRG alternatives, this simple model does not require special training or subjective decision-making.

Cost of living for infants weighing 1,000 grams or less at birth.

This article reports the in-hospital cost of caring for 75 infants weighing 1,000 gm or less at birth who were born during the 2 1/2-year period between January 1973 and June 1975. Thirty infants (40%) survived. Nineteen of 27 infants tested (70%) appear to be neurologically and developmentally "normal" at 1 to 3 years of age. Hospital charges were adjusted to September 1976 rates and corrected for a 94% collection rate. Physicians' fees represented less than 5% of the total bill and were not included. The average adjusted daily and total costs for the 45 infants who died were $825 and $14,236, respectively. The average adjusted daily and total costs for the 30 survivors were $450 and $40,287, respectively. The average adjusted total cost per "normal" survivor was $88,058. It is our belief that the outcome justifies this expense. Society, however, must be the ultimate judge.

Hypothalamic-pituitary-adrenal axis function in very low birth weight infants treated with dexamethasone.

The effect of dexamethasone therapy on hypothalamic-pituitary-adrenal axis function was prospectively investigated in very low birth weight infants with bronchopulmonary dysplasia. Ten infants (mean +/- SD birth weight 825 +/- 265 g, gestation 25.8 +/- 1.9 weeks, postnatal age 33.1 +/- 17.7 days) initially received intravenous dexamethasone, 0.5 mg/kg per day for 3 days, and then were weaned over a period of 45 +/- 19.0 days to a replacement dose, followed by a metyrapone test. Morning plasma cortisol and 11-deoxycortisol levels were measured before and after an oral metyrapone dose given at midnight. Five infants (group A: birth weight 876 +/- 313 g, gestation 26.2 +/- 1.3 weeks, age of entry 31.8 +/- 22.8 days) had normal metyrapone test results, and five infants (group B: 778 +/- 234 g, 25.4 +/- 2.5 weeks, 34.4 +/- 13.4 days) had suppressed test results. Group A infants, in comparison with group B infants, had higher basal cortisol plasma levels (14.52 +/- 12.53 and 3.00 +/- 1.38 micrograms/dL, P = .047), higher postmetyrapone 11-deoxycortisol plasma levels (3.11 +/- 3.93 and 0.55 +/- 0.51 micrograms/dL, P = .028), larger differences between basal and postmetyrapone cortisol levels (7.10 +/- 4.67 and 2.12 +/- 1.31 micrograms/dL, P = .047), and larger differences between basal and postmetyrapone 11-deoxycortisol levels (2.99 +/- 3.93 and 0.29 +/- 0.25 micrograms/dL, P = .009). The hypothalamic-pituitary-adrenal axis function in group B infants eventually returned to normal when they continued to receive low-dose dexamethasone therapy after a period of 36.8 +/- 16.6 days.(ABSTRACT TRUNCATED AT 250 WORDS)

Nonimmunologic hydrops fetalis.

Eight cases of nonimmunologic hydrops fetalis (HF) were seen at Cedars-Sinai Medical Center over a 3.5-year period. The etiology of the HF included 2 cases of fetal-maternal hemorrhage and 1 each of sacral teratoma, tachyarrhythmia, diaphragmatic hernia, neuroblastoma, and heart disease. For 1 infant, the cause was never found. These cases involved various diagnostic and therapeutic dilemmas. Only 4 were anticipated ant partum by ultrasound scanning. Two of the 8 fetuses died in utero, whereas 4 others died in the neonatal period. Earlier diagnosis and evaluation are likely to improve these outcomes.

Maternally administered antenatal vitamin K1: effect on neonatal prothrombin activity, partial thromboplastin time, and intraventricular hemorrhage.

Infants weighing 1500 g or less at birth are susceptible to intraventricular hemorrhage. This may be due in part to low concentrations of vitamin K-dependent clotting factors. Women in labor between 24-34 weeks' gestation were selected, according to their hospital registration number, to receive 10 mg vitamin K1 intramuscularly at least four hours before delivery. Control women received no vitamin K. The study included only infants born of mothers who were in hospital more than four hours before delivery, who weighed 1500 g or less at birth, and were less than 34 weeks' gestation. Twenty vitamin K1 and 33 control infants qualified for the study. Infants in both groups received routine postnatal vitamin K1. On admission, the infant's prothrombin activity and partial thromboplastin time (PTT) were measured. A head ultrasound was done between days 2 and 4 of life. Results demonstrated significantly improved prothrombin activity, a nonsignificant trend toward improved PTT, and a significantly decreased frequency of intraventricular hemorrhage in infants whose mothers had received vitamin K1. The effect of antenatal vitamin K1 on prothrombin activity and PTT appeared to be more pronounced in female infants.

Anencephalic infants: life expectancy and organ donation.

Between 1978 and 1982, 205 anencephalic infants weighing more than 2,500 g were born alive in California. Although typically none were offered significant support, almost 9% lived more than one week. It seems reasonable to assume that modern intensive care would have increased survival times dramatically. In fact, preliminary data from centers specializing in neonatal organ transplantation demonstrate that seven to 14 days of ventilatory support can be accomplished for anencephalic infants without occurrence of brainstem death. Given these data and medical information that clearly establishes anencephalic infants as a "special case" of children who have not suffered brain death but could reasonably be used as organ donors, we believe that parents who wish to do so should be allowed to continue ventilatory support for their anencephalic children for whatever period of time is necessary to find organ recipients and arrange for organ donation. Arbitrary cutoff points for intensive care and artificial criteria for brain death should not be necessary to allow the use of anencephalic infants as organ donors. We believe that current laws should be changed to permit this scenario.

Changing attitudes of neonatologists toward ventilator support.

Two identical questionnaires were completed by neonatologists in Southern California, one in 1979 and the other in 1985. All questions addressed only the issue of ventilator support. Respondents were asked to assume both parents wished ventilator support withheld or discontinued. In 1985, despite parents' wishes, neonatologists were more willing to start and continue ventilator support in smaller and less mature infants than in 1979. In 1985, but not 1979, respondents frequently would use ventilator support significantly more than they thought they should. Additionally, in both 1979 and 1985 it was more difficult for respondents to withhold ventilator support in infants with acquired versus congenital problems.

Evaluation of neonates born with intrauterine growth retardation: review and practice guidelines.

Intrauterine growth retardation affects approximately 10% of live-born infants. Causes of intrauterine growth retardation are heterogeneous, and frequently the care of these infants poses a diagnostic and therapeutic challenge. Diagnosis of impaired fetal growth is an area in which close collaboration among the obstetrician, pediatrician, and dysmorphologist is essential for proper care of these newborns. It is axiomatic that the best way to care for these infants is to establish an accurate diagnosis prenatally or soon after birth and to manage on that basis. An algorithm for evaluation and management of intrauterine growth retardation that is based on available empiric data is presented. These guidelines are intended to guide medical practice and not to replace clinical judgment.

Management of neonates born to mothers with group B streptococcus colonization.

Approximately 20% of pregnant women harbor group B streptococcus (GBS) in the lower genital tract at the time of delivery. Intrapartum chemoprophylaxis of mothers with GBS colonization who have risk factors for neonatal GBS at delivery improves the outcome of the neonates. The recommendations for treating newborn infants of mothers who receive intrapartum chemoprophylaxis for GBS colonization and the recommendations for those who do not remain empiric, because clinical studies to support such recommendations are not available. An algorithm for treatment of neonates born to mothers with GBS colonization that is based on available data and empiric recommendations is presented. These guidelines are intended to guide medical practice and not to replace clinical judgment.

Treatment decisions for newborns at the threshold of viability: an ethical dilemma.

The major ethical issues involved in decision-making in the care of extremely low birth weight newborns are analyzed here. We propose a schema for assessment and management of these infants that is consistent with ethical principles broadly accepted by the pediatric community, and which takes into account mortality risk at any given institution rather than arbitrary weight limits, with a major decision-making role for the infant's parents. When possible, the decision of whether or not to resuscitate should be made before delivery; when not possible, delivery room resuscitation is recommended, and the decision to continue or withdraw care should be made subsequently based on likelihood of survival and the wishes of the parents.

Prevention of hypogammaglobulinemia of prematurity with intravenous immune globulin.

We evaluated the effect of 1 g/kg intravenous immune globulin (IGIV) on immunoglobulin levels and half-life, the dose and frequency of IGIV administration necessary to maintain IgG levels at greater than 400 mg/dL, and IGIV effect on immunoglobulin levels after discharge in infants less than or equal to 32 weeks' gestation and less than or equal to 1500 g. Fifteen infants received 31 infusions at IgG levels less than or equal to 400 mg/dL. Immunoglobulin levels were obtained 24 hours postinfusion, weekly during hospitalization, and monthly after discharge. Mean IgG postinfusion was 980 mg/dL. Mean IgG half-life was 18 days (range 7 to 41). Smaller infants with greater than or equal to 5% of blood volume removed per week experienced shorter immunoglobulin half-lives. IGIV caused increased IgG levels after discharge and did not delay endogenous production of IgG. We conclude that 1 g/kg IGIV given to infants less than or equal to 32 weeks' gestation and less than or equal to 1500 g every 1 to 6 weeks during hospitalization, depending on weight and blood volume removed, prevents hypogammaglobulinemia of prematurity.

Neonatal intensive care unit: basic equipment needs.

Intelligent selection and use of neonatal equipment are essential for quality care. Desirable features of monitors, ventilators, and diagnostic-therapeutic equipment are elucidated.

Successful surgical repair of iatrogenic lung perforation in a neonate.

Iatrogenic lung perforation during closed tube thoracostomy for pneumothorax in neonates apparently occurs with disturbing frequency. This potentially lethal complication may be minimized by strict adherence to proper technique. In addition, an added margin of safety may be established by allowing some air to remain in the pleural space prior to placement of a chest tube. If iatrogenic perforation of the lung occurs despite appropriate precautions, surgical intervention may be indicated.

A new approach to congenital posterolateral diaphragmatic hernia.

The theory is advanced that increased pulmonary vascular resistance, resulting in a state of fetal circulation, with right-to-left shunting through the ductus arteriosus, is the main reason that many patients do not survive after repair of a diaphragmatic hernia. Three patients are presented (who, by Raphaely's criteria, were destined for a fatal outcome) in whom the ductus was ligated, and vasodilator drugs were infused into the pulmonary artery. All three demonstrated definite improvement in oxygenation. Two expired after 6 days, one of whom was found at autopsy to have intestinal volvulus and gangrene, and the other multiple plumonary emboli. One case, so managed, survived. The suggestion is made that pulmonary hypoplasia is not the main reason for the high mortality rate after diaphragmatic hernia repair, and that additional laboratory and clinical investigation of the pulmonary circulation may lead to significant improvement in results.

The antepartum diagnosis of conjoined twins.

This is a case report in which the diagnosis of conjoined twins was made in a woman by ultrasonography in her eigth month of pregnancy. With this diagnosis, the mother-to-be was transported to a hospital with sophisticated obstetrical, neonatal, and pediatric surgical facilities. The twins were delivered by elective caesarian section and were seen to have anomalies requiring immediate surgery. Following stabilization and basic investigations, surgery was performed on the infants at 3 hr of age. This resulted in a condition that permitted a thorough postoperative work-up and elective separation several months later.

Mesenchymal hamartoma of the liver responsive to cyclophosphamide therapy: therapeutic approach.

A newborn infant is described with a highly vascular hepatic mesenchymal hamartoma causing hydrops fetalis, congestive heart failure, and consumption coagulopathy. There was a remarkable response of this life-threatening condition to cyclophosphamide therapy. A review of the various alternative therapeutic modalities is presented.

Spontaneous regression of cardiac rhabdomyoma in tuberous sclerosis.

Life-threatening cardiac rhabdomyoma in a newborn infant regressed spontaneously within a 5 month period. Since cardiac surgery for rhabdomyoma is dangerous in infancy, medical management should be considered if symptomatology is not severe. When a fetal arrhythmia is diagnosed, antenatal ultrasound examination for presence of cardiac tumors is warranted.