Positive rolandic sharp waves in the EEG of the premature infant.

Ninety-seven EEGs from 30 premature infants found to have multifocal white matter necrosis on ultrasound (US) or autopsy were reviewed retrospectively. Twenty infants had intraparenchymal echodensities on US that developed into cystic lesions, a finding consistent with periventricular leukomalacia; 8 had intraparenchymal hemorrhages; and 2 had white matter necrosis at autopsy. Four of these infants had no intraventricular hemorrhage. Positive sharp waves in the central (rolandic) regions (PRS) were identified in 22 of these 30 infants (73%) and in 0 of 30 age-matched controls (p less than 0.001). The presence of PRS on the EEG of the premature infant has a high correlation with white matter necrosis rather than with intraventricular hemorrhage. In all cases, this EEG pattern was present prior to the development of cavitations when echodensities were present on US.

Diagnosis and follow-up of intraventricular and intracerebral hemorrhages by ultrasound studies of infant's brain through the fontanelles and sutures.

A technique to diagnose subependymal hemorrhage (SEH), intraventricular hemorrhage (IVH), intracerebral hemorrhage, and posthemorrhage hydrocephalus in tiny infants, using real time ultrasound studies of the brain ventricular system, is described. This is a bedside technique that visualizes the brain through the fontanelles and the sutures, in three planes: coronal, sagittal, and horizontal. Excellent visualization of the ventricular system, caudate nuclei, the thalamus, the choroid plexus, the corpus callosum, and the foramen of Monro is obtained. This method has good definition using high frequency transducers since there is no bone interference. The ultrasound diagnosis correlated well with computed tomography (CT) and with direct pathologic studies. This technique was more sensitive in diagnosing small IVH/SEH and organized clots than were CT studies. IVH/SEH were found in 90% of 113 infants less than or equal to 34 weeks of gestation; 49% of the hemorrhages were large and 41% were small. Most hemorrhages were found in the first scan, usually shortly after birth. Twenty-one premature infants who never had perinatal asphyxia or respiratory distress syndrome had IVH/SEH. The hemorrhages were followed until disappearance, usually in one to three months in cases of large hemorrhages.

Dating the time interval from meconium passage to birth.

The gross and microscopic effects of exposing placenta and umbilical cord to meconium were studied in vitro. Gross staining begins with one hour and is a surface phenomenon proportional to length of exposure and meconium concentration. Pigment penetration into the membranes with subsequent uptake by macrophages is dependent primarily on exposure length. Eight of 11 placentas exposed to various meconium solutions were found to have meconium pigment-laden macrophages in the amnion after one hour. These were seen in the chorion somewhat later. Although only three of 11 placentas showed chorionic pigmented macrophages at one hour, 12 of 12 exhibited this finding after three hours. Amniotic epithelial degeneration also showed a time correlation. These findings, especially the microscopic changes described, permit more accurate determination of the defecation-to-birth interval.

Focal necrosis of the white matter (periventricular leukomalacia): sonographic, pathologic, and electroencephalographic features.

Eleven preterm infants (gestational ages 27-35 weeks) with echogenic paraventricular white matter identified shortly after birth were studied with serial echoencephalograms to fully delineate the sonographic findings characterizing the pathologic stages of white-matter necrosis. Echoencephalograms were compared with autopsy findings and CT scans. Cerebral function was assessed by electroencephalograms and later by neurodevelopmental evaluations. Echogenic areas were observed in the paraventricular white matter in the acute stage. Microscopically, the echogenic white matter consisted of vascular congestion and petechial hemorrhages, but not always with foci of necrosis. Anechoic areas, which characterized the chronic stage, corresponded to cavitary lesions, and these generally appeared within 2 weeks of birth. However, six infants had anechoic lesions by day 4, suggesting that the onset of white-matter damage was antenatal. CT showed mildly decreased attenuation when paraventricular echogenic areas alone or in association with small anechoic areas were observed. Markedly decreased attenuation on CT scans corresponded to large anechoic areas. Resolution of the sonographic and CT findings did not indicate normalization of the white matter since all surviving infants were neurologically abnormal at 1 year. Electroencephalograms with central (rolandic) positive sharp waves were associated with echogenic white matter alone or with evolving anechoic areas. All patients with positive sharp waves on electroencephalograms had large anechoic areas in later studies. Early and serial echoencephalograms are necessary to evaluate white-matter necrosis in preterm infants. When echogenic white matter is identified, electroencephalography can suggest the presence of white-matter necrosis.

Real time ultrasound diagnosis of hemorrhagic pathological conditions in the posterior fossa of preterm infants.

Real time echoencephalography (RTE) was used to diagnose and serially follow intracranial pathological conditions in the posterior fossa of infants with a gestational age of less than 34 weeks. The posterior fossa was studied in four planes (coronal, modified coronal, sagittal, and parasagittal) with a sector scanner equipped with a high frequency transducer that was placed on the fontanelles and the sutures. Hemorrhagic complications were easily differentiated from normal anatomy. RTE diagnosis was confirmed with computed tomographic scans (5 patients) and postmortem examination of the brain (18 infants). RTE is a precise and noninvasive technique to visualize hemorrhagic and other forms of abnormalities in the infratentorial compartment.

Prognostic value of EEG in neonatal meningitis: retrospective study of 29 infants.

Neonatal meningitis is associated with significant neurologic sequelae. Previous studies from our laboratory and others demonstrated electroencephalography (EEG) to be a useful tool in predicting long-term neurologic outcome in at-risk neonates. We, therefore, retrospectively studied 29 infants with culture-proved neonatal meningitis who died in the neonatal period or survived to follow-up at a mean of 34.4 months. Seventy-five EEGs were obtained during the acute phase of infection; the degree of EEG background abnormality proved to be an accurate predictor of outcome. Infants who had normal or mildly abnormal backgrounds had normal outcomes, whereas those with markedly abnormal EEGs died or manifested severe neurologic sequelae at follow-up. When the EEG was considered with the presence or absence of seizures and the level of consciousness, an accurate prediction of neurologic outcome was obtained in 27 infants (93%). Although the EEG patterns were generally nonspecific, some abnormalities, such as positive rolandic sharp waves, persistent hemispheric or focal voltage attenuation, suggested more specific pathology (i.e., deep white matter necrosis, large-vessel infarction and abscess, respectively). EEG was also valuable for the recognition of subtle and subclinical seizures. Therefore, we conclude that EEG is a valuable tool for predicting the long-term prognoses of infants with neonatal meningitis.

Survival of a preterm twin following infarction of the right hepatic lobe.

Survival following hemorrhagic necrosis of a lobe of the liver in preterm infants is very uncommon. We present the clinical and radiologic findings of such a case, discuss the clinical management of the hemorrhage that resulted in the infant's survival, and present a basis for the evolution of the liver pathology.

Training of personnel-pediatrics.

The educational programs that have been developed in newborn special care facilities have two purposes: first, they teach personnel the manual skills that are necessary to manage the sick newborn infant; second, they provide personnel with a better understanding of neonatal pathophysiology so that they can begin to recognize the subtle responses of the sick neonate. With these skills and knowledge, the nursery staff assumes a more active role in the team's effort to preserve a child's life.

Bilirubinemia in asphyxiated term infants. A clinical observation.

Recent clinical observations suggested that serum bilirubin levels remain low following perinatal asphyxia. This study was performed to determine the peak serum bilirubin concentrations in asphyxiated term infants and to compare these levels with those in a group of non-asphyxiated term infants. The medical records of 28 asphyxiated (Apgar < 7 at 5 minutes) and 947 non-asphyxiated term infants born during the same period of time were reviewed to obtain data on peak serum bilirubin concentrations for statistical comparison. The statistical mean for the peak serum bilirubin concentrations in the 28 asphyxiated infants was 5.0 mg/dl (+3.1 SD) while that for the 947 non-asphyxiated infants was 8.9 mg/dl (+3.7, p < .001). The findings in this study indicate that low peak bilirubin levels should be expected in asphyxiated term infants and may be helpful as a biochemical marker before the mechanism of action is known.

Coagulation studies in infants of diabetic mothers.

Coagulation studies on 17 infants of diabetic mothers were compared with 11 control infants. Only minor differences were noted, including lower platelet counts in the former group. On the basis of these findings, the increased thrombotic tendency in diabetic progeny cannot be attributed to altered hemostasis.

[Rhythmic alpha activity in the EEG of premature and newborn infants]. / Rhythmische alpha-Aktivität im EEG von Früh- und Neugeborenen.

The EEG of the newborn consists of a mixed activity which varies from 1 to 22/s. Waves in the alpha band may occur, but they indicate cerebral dysfunction if they are seen in a rhythmic uninterrupted sequence. Eight newborns who showed rhythmic alpha activity in their EEG are included in our study. This activity occurred together with rhythmic theta waves or was followed by them as part of ongoing electrographic seizure activity. All newborns studied were very sick. Three suffered from severe perinatal asphyxia with persistent fetal circulation; in addition one of them had bacterial meningitis. Two infants suffered from herpes encephalitis. In those cases the rhythmic alpha activity temporarily showed a certain periodicity. This EEG pattern was also seen in a small for gestational age premature infant who had septicemia and subarachnoid hemorrhage and in two extremely premature babies with intraventricular hemorrhage. Four infants were curarized. All of the others also had clinically observed seizures. Rhythmic alpha-activity in the neonatal EEG represents an electrical seizure discharge. It may also occur in premature infants who suffer from intraventricular hemorrhage. Obviously it does not have a diagnostic value. The prognostic value depends upon the underlying disease and the grade of background suppression in the EEG. Anticonvulsant therapy should be administered early using a sufficient dosage.

Bacteremic infection with Pediococcus: vancomycin-resistant opportunist.

Pediococci are recently recognized Gram-positive human pathogens, resistant to vancomycin and generally susceptible to penicillin. Infection in adults has been seen in patients with chronic underlying conditions as well as those with previous abdominal surgery. Two previous infants with congenital gastrointestinal malformations requiring surgical correction have been reported with sepsis attributable to Pediococcus sp. We report a third infant born with gastroschisis who developed Pediococcus bacteremia and meningitis 3 months after surgery, and speculate regarding the role of probiotics in the pathogenesis of this infection.

Electroencephalographic and neuroimaging findings in neonates undergoing extracorporeal membrane oxygenation.

Electroencephalograms (EEGs) were recorded on 36 infants who were treated with arteriovenous extracorporeal membrane oxygenation (ECMO) between 1986 and 1989. Twelve of 36 infants had EEGs prior to and during ECMO. Twenty-one infants who met ECMO criteria but were treated with mechanical ventilation only served as a comparison (COMP) group. Electrographic seizures occurred in 7 of the 36 (19%) ECMO patients and in 3 of the 21 (14%) COMP patients. Five of 7 ECMO infants had electrographic status epilepticus. Three infants developed electrographic seizures during ECMO in association with an acute cerebral injury. These patients did not have significant hemispheric predominance in the origin of electrographic seizures (2 right, 3 left and 2 bilateral). Repetitive or periodic discharges (RPD) with frequencies between 0.5 and 5 Hz were seen after starting therapy in 23 of the 36 (64%) ECMO patients and 15 of the 21 (71%) of the COMP group. Only in the ECMO patients did RPD arise significantly more frequently from the right hemisphere (13 right, 4 left and 6 bilateral; p = 0.015). Neuroimaging studies showed evidence of ischemic lesion in 8 of the 36 (22%) ECMO patients with significantly right-sided predominance (5 right, 1 left and 2 bilateral; p = .05). Cerebellar hemorrhages occurred in 3 ECMO patients. Ischemic lesions occurred in 3 of the 21 (14%) COMP patients, all occurring on the left side. In the ECMO group, severe outcome or death was significantly associated with the presence of electrographic seizures, status epilepticus, and suppression-burst pattern (p < 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

Detection of neonatal seizures through computerized EEG analysis.

Neonatal seizures are a symptom of central nervous system disturbances. Neonatal seizures may be identified by direct clinical observation by the majority of electrographic seizures are clinically silent or subtle. Electrographic seizures in the newborn consist of periodic or rhythmic discharges that are distinctively different from normal background cerebral activity. Utilizing these differences, we have developed a technique to identify electrographic seizure activity. In this study, autocorrelation analysis was used to distinguish seizures from background electrocerebral activity. Autocorrelation data were scored to quantify the periodicity using a newly developed scoring system. This method, Scored Autocorrelation Moment (SAM) analysis, successfully distinguished epochs of EEGs with seizures from those without (N = 117 epochs, 58 with seizure and 59 without). SAM analysis showed a sensitivity of 84% and a specificity of 98%. SAM analysis of EEG may provide a method for monitoring electrographic seizures in high-risk newborns.