Evaluation of pulmonary vascular resistance in the presence of a large pulmonary arteriovenous malformation.

A 1 day old infant presented with severe cyanosis and congestive heart failure. Cardiac catheterization confirmed the clinical suspicion of a pulmonary arteriovenous malformation of the right lower lobe. Catheter occlusion of the right lower pulmonary artery allowed evaluation of the integrity of the remaining pulmonary vascular bed as well as improvement of the patient's hemodynamic condition pending more definitive therapy.

Earlier discharge with community-based intervention for low birth weight infants: a randomized trial.

BACKGROUND: Prolonged hospitalization of low birth weight infants increases the risk of medical and psychosocial complications. The feasibility of earlier discharge with community-based follow-up of infants of < or = 2000 g birth weight, without the use of home apnea monitors, was investigated. METHODS: One hundred infants of < or = 2000 g birth weight were randomized to either an intervention or control group. Intervention infants were discharged when readiness criteria were met. Based on assessed need, intervention group families received public health nursing and homemaker services for up to 8 weeks. Control infants were discharged to their homes at the discretion of the attending physician. All infants were assessed blindly at age 1 year with the Bayley and Home Observation for Measurement of the Environment (HOME) scales. RESULTS: There were no group differences in baseline infants' characteristics or in neonatal complications. Infants in the intervention group were discharged from the hospital at an earlier postconceptional age (mean +/- SD 36.6 +/- 1.5 weeks vs 37.3 +/- 1.6 weeks; P < .04). Median length of hospital stay (23 days vs 31.5 days) and mean weight at the time of discharge (2200 +/- 288 g vs 2275 +/- 301 g) were lower, but not significantly, for infants in the intervention group. A secondary analysis by birth weight strata (< or = 1500 g and 1501 through 2000 g) revealed that the most significant reductions in hospital stay and weight at discharge were realized in infants of 1501 through 2000 g birth weight. The persistence of apneic episodes and need for electronic monitoring prevented earlier discharge of infants of < or = 1500 g birth weight. Postdischarge services to the intervention group included 185 public health nurse home visits (3.8 +/- 0.91), 410 phone contacts (8.4 +/- 5), and 2298 homemaker hours (46 +/- 78) of service. At 1 year, there were no deaths and no group differences in rehospitalization rates, use of ambulatory services, or Bayley scores. Intervention families had significantly higher 1-year HOME scores. Minimum cost of hospital care was $873 per day, while the total cost of community-based services averaged $626 per infant. CONCLUSIONS: A significant reduction in average length of hospital stay was achieved for infants of 1501 through 2000 g birth weight. Earlier discharge of infants weighing < or = 1500 g at birth was hampered by persistent apneic episodes and feeding difficulties. A community-based program designed to provide individualized support and education for families of low birth weight infants was cost-effective and had a positive influence on the home environment.

The impact of very low-birth-weight infants on the family is long lasting. A matched control study.

OBJECTIVE: To test the hypothesis that parental stress associated with long-term morbidity of very low-birth-weight infants (VLBWIs) is long lasting. DESIGN: Matched case-control study. SETTING: High-risk newborn follow-up program, Winnipeg, Manitoba. PARTICIPANTS: Parents of 96 Manitoban VLBWIs born from July 1986 through June 1990, compared with parents of full-term controls matched for age, sex, race, domicile, singleton or multiple pregnancy, and birth order. MAIN OUTCOME MEASURES: Mailed questionnaire, including Stein's Impact on Family Scale, positive impact of parenthood, and attitudes toward treating VLBWIs. RESULTS: Families were demographically similar. The parents of VLBWIs had higher scores for financial burden, familial/social impact, personal strain, and mastery (P < .0001). The parents of VLBWIs experienced more impact when children had a functional handicap or low adaptive developmental quotient. Scores were highest when the adaptive developmental quotient was 70 to 85. High scores were associated with low family income and less parental education. Impact did not change over time. Only half of the parents in each group felt that "doctors should try to save every baby." The parents of VLBWIs felt more strongly that cost should never enter into the decision to treat a tiny baby (P < .005). The families of VLBWIs expressed a stronger desire for more children (P < .01), but control families were more likely to have given birth again (46.3% vs 28.2%). CONCLUSIONS: The birth and upbringing of a VLBWI is associated with more long-term stress, even for well-educated nuclear families whose health care is financed by government. Caregivers need increased awareness of the needs of these families so that their medical and social needs are met effectively. Support services should be targeted toward low income, poorly educated parents whose children have functional handicaps.

Neonatal withdrawal from maternal volatile substance abuse.

AIM: To determine whether neonates born to mothers who are volatile substance abusers are at risk for an abstinence syndrome. METHODS: A consecutive sample of infants born to volatile substance abusing mothers was studied over four years, in a university affiliated medical centre with a variable mix of primary, secondary, and tertiary care patients. Infants were clinically scored with the Finnegan Neonatal Abstinence Scoring System. Those who fulfilled a priori scoring criteria were treated with phenobarbital and scoring was continued. RESULTS: There were 48 babies of whom 32 fulfilled the criteria for pharmacotherapy. All eight babies with the characteristic odour, and 15 of the 21 born to mothers with that odour, fulfilled these criteria. The typical symptoms were excessive and high pitched cry, sleeplessness, hyperactive Moro reflex, tremor, hypotonia, and poor feeding. Mean age of onset of treatment was 27.1 hours and mean duration was 5.8 days. Treatment was judged effective in 17 of 27, while benefit was borderline in three and absent in seven. CONCLUSIONS: It is suggested that there is an identifiable neonatal volatile substance abuse abstinence syndrome. The characteristic chemical odour in the neonate or mother is a marker for its occurrence, and phenobarbital treatment seems to be effective. The Finnegan Scoring System seems to be useful for grading its severity.

The natural history and predictive value of early language delays in very low birth weight infants.

A cohort of 28 VLBW (less than or equal to 1500 g) infants was assessed at 1 and 3 years of age for hearing, language development and neurological status. Language delays were detected in 11 (39%) infants at 1 year, and in four (15%) at follow up at 3 years of age (P less than 0.05). Language quotients were significantly associated with perinatal variables at 1 but not at 3 years of age. Infants with neurological abnormalities had significantly lower language quotients at the 3-year follow up. No child with a normal language profile at 1 year exhibited a delay at 3 years of age.

Language development of very low birth weight infants and fullterm controls at 12 months of age.

Twenty-eight very low birth weight (VLBW) and 32 full term infants were prospectively assessed at one year of age for hearing, language development and neurological status. The prevalence of conductive hearing deficits was the same in both groups. Language scores in VLBW infants were significantly lower than in fullterm controls and 39% had significant language delays. VLBW infants exhibited a shorter attention span and were less likely to understand simple questions, to recognize objects or body parts when named, to initiate speech-gesture games, to follow simple commands and to imitate or use words consistently. Language quotients were directly associated with gestational age and five minute Apgar scores and inversely associated with severity of intraventricular hemorrhage, bronchopulmonary dysplasia and length of hospital stay. VLBW small for gestational age infants exhibited more advanced language skills than VLBW appropriate for gestational age infants. Language delays were more prevalent among, but not limited to, infants with mild to moderate neurological abnormalities. The influence of prematurity and VLBW on language development is complex and multifactorial and research is continuing to determine the predictive validity and long term significance of the early language delays described in this study.

Treatment of children with autism: a randomized controlled trial to evaluate a caregiver-based intervention program in community day-care centers.

This study reports on the results of a randomized controlled trial that evaluated a caregiver-based intervention program for children with autism in community day-care centers. Thirty-five preschool children with a DSM III-R diagnosis of autism or pervasive developmental disorder were randomized to an experimental or control group. Children in the experimental group were enrolled in day care and their parents and child care workers received a 12-week intervention consisting of lectures and on-site consultations to day-care centers. In addition, supportive work was undertaken with families. Control subjects received day care alone. In the experimental group, there were greater gains in language abilities, significant increases in caregivers' knowledge about autism, greater perception of control on the part of mothers, and greater parent satisfaction. We conclude that this research design demonstrated that the intervention was significantly superior to day care alone.

Public awareness of the risks of drinking alcohol during pregnancy: the effects of a television campaign. Child Health Committee, Manitoba Medical Association.

OBJECTIVE: To evaluate the impact of a television public awareness campaign on knowledge of the dangers of drinking alcohol during pregnancy. DESIGN: A survey with five questions on alcohol and pregnancy and five health questions unrelated to alcohol was administered before and after the campaign. PARTICIPANTS: Three thousand women aged 15-45 years. INTERVENTION: A 30-second announcement with a message on alcohol and pregnancy was broadcast over ten weeks by five television stations in Manitoba. RESULTS: More respondents after the campaign thought that alcohol consumption in pregnancy would put the baby at risk, and attributed this information to "television". There were no differences in the responses to the five health questions unrelated to alcohol. CONCLUSIONS: An increase in awareness of the risks of drinking alcohol during pregnancy was observed after a mass media campaign.

Persistent neonatal hypoglycemia: Diagnosis and management.

Maintenance of plasma glucose depends on a normal endocrine system, functional enzyme levels for glycogenolysis, gluconeogenesis and other processes, and there must be an adequate supply of endogenous fat, glycogen and substrates of gluconeogenesis. Neonatal hypoglycemia should be defined as serum glucose less than 2.2 mmol/L in the first 72 h of life and less than 2.5 mmol/L thereafter. The purpose of this paper is to review the more uncommon causes of hypoglycemia in the full term, apparently healthy neonate. Most of these conditions are inborn errors of metabolism. A protocol for investigation of these conditions and some of the more common diseases, such as hyperinsulinism, is provided, with a rationale explaining why these tests may be helpful.

Neurodevelopmental outcome of term infants with intraventricular hemorrhage.

Intraventricular hemorrhage and its sequelae have been reported infrequently in term infants. We investigated the outcome of intraventricular hemorrhage in 15 term infants born between 1982 and 1988. One infant (7%) died. Complications of pregnancy were identified in seven mothers (47%). Age at diagnosis ranged from in utero to 28 days. Clinical presentation included feeding intolerance, fever, jaundice, irritability, and seizures. Severity of hemorrhage was of prognostic value. Of the four children with grade 4 hemorrhage, one died and the three survivors were severely handicapped. Overall, nine (64%) of 14 survivors had no or mild handicap. Perinatal alloimmune thrombocytopenia emerged as the single most important cause of severe hemorrhage and poor outcome. Identification and treatment of these infants must begin in utero if we are to prevent intraventricular hemorrhage and its complications in this group of patients.

Neurodevelopmental outcome of infants exposed to indomethacin antenatally.

The use of indomethacin as a tocolytic agent has been limited because of potential fetal and neonatal complications. We investigated the neonatal and neurodevelopmental outcome of preterm infants exposed antenatally to this drug. The records of 779 women admitted in premature labor during a five year period were reviewed. Nineteen women who received indomethacin (initial dose of 50-100 mg followed by 50-100 mg/day) and their 25 infants were identified. Delivery was delayed for a week or longer in 86.6% of the mothers. There were two deaths: a stillborn with multiple congenital anomalies and a neonate with congenital listeriosis. Seven infants were born at term without complications. Fifteen infants born prematurely were compared to 15 control infants not exposed to indomethacin antenatally. There were no statistically significant differences between the two groups in the prevalence or severity of thrombocytopenia, hyperbilirubinemia, intraventricular hemorrhages, patent ductus arteriosus, persistent pulmonary hypertension, bronchopulmonary dysplasia, and necrotizing enterocolitis. Mean BUN, creatine, and urine output for the first three days of life were similar in the two groups. No differences were found at the 6-12 month neurodevelopment assessment. We found no neonatal complications attributable to the antenatal use of indomethacin.

Intravenous pentazocine and methylphenidate abuse during pregnancy. Maternal lifestyle and infant outcome.

OBJECTIVE: To report the effects of intravenous abuse of pentazocine hydrochloride and methylphenidate hydrochloride during pregnancy. DESIGN: Retrospective chart review. PATIENTS: All pregnant women and their offspring, whose hospital records indicated prenatal abuse of pentazocine and methylphenidate during the 2-year study period. RESULTS: The median for maternal age was 22 years and the median number of prenatal visits was two. Twenty mothers had sexually transmitted diseases, 27 abused alcohol, 10 abused other drugs, and all smoked cigarettes. Eight infants were premature, and 12 were growth retarded. Four infants had congenital anomalies: fetal alcohol syndrome (two [twins]), structural heart defect (one), and polydactyly (one). Eleven infants were treated for neonatal abstinence syndrome. Seventeen infants had normal developmental quotients, and four had low-normal developmental quotients. CONCLUSIONS: Intrauterine exposure to pentazocine and methylphenidate appears to be associated with prematurity, growth retardation, and signs of neonatal withdrawal, but not with any particular teratogenic anomaly or severe developmental delay.

Liver development in a rat model of fetal alcohol syndrome.

The inhibitory effects of alcohol on hepatic growth in adults raises the possibility that the liver may be involved in fetal alcohol syndrome (FAS) in infants. To test this hypothesis, pregnant Sprague-Dawley rats were fed liquid diets containing either ethanol as 36% of the total calories, or were allowed ad libitum feeding of a control liquid diet (controls) throughout pregnancy. Other dams were exposed to the ethanol diet only during the first or last half of pregnancy. Pups delivered of dams exposed to the various diets (N = 40-45/group) were killed at 1, 3, 7, and 14 days of age. In addition to brain weights, crown-rump lengths, and facial features, the following parameters of liver development were documented; liver weight, liver/body weight ratio, liver histology, hepatic ornithine decarboxylase activity (ODC), hepatic protein content, and rate of hepatic DNA synthesis (as determined by [3H]thymidine incorporation). The results revealed that pups exposed to ethanol throughout pregnancy but not ad libitum control diet pups had brain weights, crown-rump lengths, and facial features in keeping with FAS. With respect to liver development, the livers in FAS pups were consistently smaller than in the control group. However, total body weights were decreased to a greater extent, such that when corrected for body weights, the smaller livers in FAS pups only became significant on day 14 of life. Liver histology was similar in the two groups with no signs of active inflammation or fibrosis. Hepatic ODC activity was also similar, indicating no impairment in polyamine synthesis. Hepatic DNA synthesis rates were decreased in FAS pups at all time intervals. Pups delivered of dams exposed to ethanol during either the first or last half of pregnancy had results comparable to those of controls. To identify the mechanism(s) responsible for these findings, a second series of experiments was performed wherein the hepatic expression of the following factors associated with liver development were documented by northern-blot analyses; growth hormone receptor (GHr), insulin-like growth factor-I (IGF-I) and -II (IGF-II) and IGF binding proteins (IGFBPs) 1, 2, 3, and 4 mRNA on gestational days 16 and 20 and postpartum days 1 and 7. In this series, a third group of pups derived from dams in whom caloric consumption was matched to that of the ethanol-fed dams (isocaloric controls) were also studied. The results revealed no consistent differences in GHr, IGF, or IGFBP mRNA expression in the three groups. In conclusion, liver development and hepatic DNA synthesis were significantly impaired in this animal model of FAS. That impairment, however, was not associated with decreases in either polyamine synthesis or disturbances in the hepatic component of the GH/IGF/IGFBP axis.