Hospital readmission and morbidity following early newborn discharge.

To examine causes of newborn hospital readmission and morbidity related to early nursery discharge, we reviewed the charts of 664 newborns readmitted from home under the age of 15 days, between 1993 and 1995. Early discharge (ED) was defined as nursery length of stay of < or = 2 days. Morbidity related to ED: onset of symptoms within 1 day of ED; and in diseases with insidious onset: serum bilirubin level > 20 mg/dL (340 mumol/L), or dehydration following poor breastfeeding since birth. Seventeen percent of all readmitted infants had ED-related morbidity; 9% had major morbidity. Onset of symptoms prior to the age of 3 days occurred in 43% of ductal-dependent cardiac lesions, intestinal obstruction, seizures, and major infections. Morbidity was less pronounced in infants who were followed up within 2 days following ED. Specific findings related to subsequent morbidity were identified in the perinatal history of infants who were readmitted with major infections and with hyperbilirubinemia. Our findings suggest that: (1) close to half of the cases with acute-onset major morbidity can be identified within 3 days of birth, and (2) attention to the perinatal history and timely follow-up will contribute to a reduction in both morbidity and complications.

Approaching the management of the neonatal intensive care unit graduate through history and physical assessment.

NICU graduates, often ex-premature infants, offer unusual challenges to the primary care provider. History and physical assessment require an organized approach with meticulous attention to detail. These infants are at high risk for multiple problems including growth delays, nutrition and feeding problems, pulmonary sequelae, neurological sequelae and developmental delays, vision and hearing disturbances, as well as abnormalities in parent-infant bonding. This article emphasizes particular aspects of the history and physical examination that signify pathophysiology and sequelae common to the NICU graduate.

Prenatal cocaine/polydrug exposure: effect of race on outcome.

OBJECTIVE: To determine the effect of prenatal exposure to cocaine on development. METHODS: We tested 106 infants in the range of 4 to 30 months adjusted age with the Bayley Scales of Infant Development. RESULTS: The 46 cocaine-exposed infants had similar mental scores to those of the 60 control infants. Among the 47 black infants, motor scores were 11.2 points higher in cocaine-exposed infants than in control infants (115.1 and 103.9, respectively, p = 0.023). Among the 59 white infants, motor scores were similar in cocaine-exposed infants (102.9) and control infants (100.6). CONCLUSION: Genetic differences may account for this variation in motor development of cocaine-exposed infants.

Cardiac arrest in an extremely low birth weight infant: complication of percutaneous central venous catheter hyperalimentation.

We report a case of unexpected sudden cardiac arrest in an extremely low birth weight infant on the eighth day after a percutaneous silicone rubber central venous catheter was inserted for parenteral nutrition. The unique pathologic condition of infiltration of the myocardium with probably intralipid and degeneration of myocardial fibers over the right atrium and part of the right ventricle has not been reported in the past. There was no pericardial effusion. A brief review of the complications of central venous catheters is given.

Identification of sepsis in neonates following maternal antibiotic therapy.

To examine the value of current diagnostic tests identifying neonatal sepsis related to intrapartum treatment with antibiotics, we reviewed the charts of 219 mother-infant pairs, of which 139 mothers received intrapartum antibiotics (group 1) and 80 mothers did not (group 2). When compared with group 2 infants, group 1 infants had fewer positive blood cultures (4.3% vs 20%, P < 0.003), blood cultures positive for group B streptococci (GBS) (P < 0.001), and positive urine GBS latex agglutination (LA) tests (P < 0.001). Although the sensitivity of the white blood cell count (WBC) was 81%, the specificity was < 60% in both groups. The specificity of the urine GBS LA test was 92%. These results suggest (1) the WBC will neither confirm nor rule out neonatal septicemia; (2) blood cultures are indicated in suspected neonatal sepsis even if there was maternal intrapartum treatment with antibiotics; and (3) a urine GBS LA test is a useful adjunct in the diagnosis of neonatal GBS septicemia.

Normal high-resolution cerebral 99mTc-HMPAO SPECT scans in symptomatic neonates exposed to cocaine.

Vascular constriction is said to account for a variety of clinical effects of cocaine. High-resolution 99mTc-hexamethylpropylene amine oxime single photon emission computed tomographic (SPECT) scans, which measure cerebral blood flow, were used to determine whether neonatal brain perfusion deficits are present in newborns with confirmed cocaine exposure. Normal, age-appropriate SPECT scans were found in 21 babies. Conventional neuroimaging was also performed when possible. All but one of the 14 magnetic resonance imaging (MRI) scans and one computed tomographic scan were normal. One MRI showed a mild delay in myelination. All but four neonates had behavioral or electroencephalographic abnormalities, and microcephaly was found in five of 21. The normal neonatal SPECT scans contrast with findings in adult cocaine users, which typically report abnormal findings of cerebral hypoperfusion. This study identifies a unique lack of corresponding cerebral vascular pathology in symptomatic neonates. It raises the possibility that many of these children can escape significant ischemic injury.

Traumatic pseudodiverticulum of the pharynx.

Traumatic pseudodiverticulum of the pharynx is a rare complication of endotracheal intubation. Prompt recognition and management will help in reducing the morbidity. A case of traumatic pseudodiverticulum of the pharynx in a preterm infant and the management with a brief review are reported.

Relationship between nutrition, weight change, and fluid compartments in preterm infants during the first week of life.

This study was conducted to investigate the redistribution of fluid compartments and to examine the factors contributing to the variability of early weight loss in premature infants. Fourteen preterm infants (mean +/- SD: birth weight, 1473 +/- 342 gm; gestational age, 30.7 +/- 2.4 weeks) were studied at 1 and 7 days of age. Total body water was measured by deuterium oxide dilution, extracellular volume by bromide dilution, and intracellular volume by the difference between total body water and extracellular volume. There were significant changes in body fluid distribution per concurrent weight from birth to age 1 week. Extracellular volume decreased by 11%, and intracellular volume increased by 8.5% with no change in total body water. Infants were then grouped according to postnatal weight loss (group 1 (n = 7) > 10% and group 2 (n = 7) < 5% of birth weight). In group 1 there was a significant loss of both weight (mean +/- SD: 15.6% +/- 3.7%) and extracellular volume (15.9% +/- 9% of birth weight), with no change in intracellular volume. In group 2 there was no significant weight loss (1.4% +/- 1.8%), but a significant loss of extracellular volume (13.0% +/- 5.4% of birth weight) and a significant increase in intracellular volume. Other differences between the groups were a lower energy intake in group 1 than in group 2 (mean +/- SD: 177 +/- 46 vs 269 +/- 45 kilojoules/kg per day; p < 0.005) and a higher physiologic stability index in group 1 (p < 0.05). We conclude that significant postnatal weight loss as a result of the contraction of the extracellular compartment occurs only in less stable infants whose energy intake is inadequate. With adequate energy intake, weight loss is minimal because of the expansion of the intracellular compartment, which may be related to the onset of growth.

Effect of positioning on the breathing pattern of preterm infants.

Respiration, as judged by gas exchange and pulmonary function, is improved in preterm infants kept in the prone rather than the supine position. The influence of position on the breathing pattern as documented by the pneumogram was studied in 14 stable preterm infants with recent clinical apnoea. Ten of the infants had oximetry and nasal flow studies simultaneously with the impedance pneumogram. Each infant had consecutive nocturnal pneumograms, one in the prone, one in the supine position. The infants were kept for more than six hours in the assigned position. A significant increase in apnoea density and in periodic breathing was found in the supine v the prone position (mean (SE) 4.5 (0.7)% v 2.5 (0.5)%, and 13.6 (3.2)% v 7.7 (2.2)%, respectively). There was no positional difference in the incidence of bradycardia and prolonged apnoea. The examination of obstructive apnoea, mixed apnoea, and cyanotic spells did not reveal a consistent disparity between the two positions. These findings indicate an increase in central apnoea in preterm infants kept predominantly in the supine position. Possible relations of positional changes to lung mechanics are discussed. When evaluating pneumograms, attention must be given to the position in which they were performed.

Transfusion-induced changes in the breathing pattern of healthy preterm anemic infants.

In order to evaluate the effects of transfusion on breathing pattern in growing, otherwise healthy, anemic preterm infants, we studied 14 infants whose mean +/- SD birthweight was 1,212 +/- 294 grams, gestational age 29.28 +/- 2.23 weeks and hematocrit 25.86 +/- 2.24%. At a mean postnatal age of 41.35 +/- 19.45 days 12 hour nocturnal (transthoracic impedance) pneumocardiograms were obtained 24 hours prior to and after transfusion with 10 mL/kg of packed red blood cells. Posttransfusion pneumocardiograms revealed significant reduction of periodic breathing, of apnea episodes with 11-15 second duration, of apnea density, and of heart rate. These findings indicate that transfusion with packed red blood cells significantly alters certain cardiorespiratory variables in anemic preterm infants.

Management of symptomatic patent ductus arteriosus in very low-birth-weight infants.

A retrospective study of 39 infants under 30 weeks' gestation was carried out to analyze the incidence, management, and morbidity resulting from symptomatic patent ductus arteriosus. Symptomatic patent ductus arteriosus developed in 21 (53.8%) infants. Eleven (52.3%) infants underwent surgical closure of the ductus. The infants in this group had lower birth weight and severe respiratory distress syndrome and higher morbidity, compared with the medically managed group. The infants who responded to medical management did not have higher morbidity compared with the control group who did not sustain symptomatic patent ductus arteriosus. Indomethacin treatment was not effective in infants with a birth weight less than 800 gm. Our findings indicate that the higher morbidity seen in the symptomatic patent ductus arteriosus group may be due to respiratory distress syndrome, surgery, and birth weight under 800 gm. Prophylactic use of indomethacin may have a doubtful value in this group.

Alterations in pulmonary mechanics after transfusion in anemic preterm infants.

Pulmonary mechanics were studied in ten anemic preterm infants using an esophageal balloon and mask, before and after transfusion with 10 ml/kg of packed RBC. Their mean birth weight was 1212 +/- 323 g and gestational age was 29.27 +/- 2.4 wk. Transfusions were carried out at a mean postnatal age of 41.9 +/- 21.8 days. The mean Hct increased from 28 +/- 3.1 to 38.3 +/- 3.3%. Dynamic lung compliance decreased in all infants after transfusion. There was a 33.8% increase in resistance; the work of breathing increased after transfusion. These changes might be due to volume overload or increased lung water content.

Chronic lung disease in premature infants: a retrospective evaluation of underlying factors.

A retrospective case-control study involving 99 premature infants requiring vigorous respiratory support was conducted to investigate the relative contribution of various etiologic factors in the development of chronic lung disease (CLD). Nineteen of the 99 developed CLD. Background and management factors up to the development of CLD, with attention to mode of ventilation (tube, or face mask/nasal prongs) were investigated. Infants in the CLD group had significantly lower birth weights (BW) (p less than .001) and gestational ages (p less than .01) than those in the non-CLD group. There was no difference in the incidence of intrathoracic airleak or symptomatic patent ductus arteriosus. Of the CLD group, 74% were intubated compared with 35% in the non-CLD group (p less than .002). There was no difference between the groups in the morbidity score of initial pulmonary disease or in the duration of ventilation with various pressures and oxygen concentrations. Multiple logistic regression analysis revealed that intubated infants were 4.8 times more likely to develop CLD than nonintubated infants, and infants with low BW had a 3.2-fold greater risk of developing the disease.

The relationships of transcephalic impedance, head growth and caloric intake to outcome in preterm infants.

Twenty-two preterm infants with birth weights less than 1 400 g were measured weekly with transcephalic impedance and occipital-frontal head circumference. Mean caloric intake/kg/day was calculated weekly. All infants were assessed at one year of age with Bayley Mental and Motor Scales and neurological assessment. Univariate and multivariate analyses were performed indicating that transcephalic impedance was the most powerful of the three measures as a predictor of sequelae.

Asphyxia and gestational age.

Perinatal asphyxia at term is a major cause of mortality and morbidity. In many instances obstetric or maternal complications during pregnancy, labor, or delivery account for the asphyxia, but there is a group of infants in whom asphyxia occurs without any recognizable risk factors. The histories of 1602 infants were evaluated with these problems in mind. There were 547 infants without any complicating factors, 329 with obstetric complications, and 356 with miscellaneous maternal, fetal, and neonatal problems. The mean gestational age of these infants was 277.4 days. Fetal distress was noted in 183 cases without subsequent neonatal disease; the mean gestation of these infants was 282.7 days. Unexpected intrapartum asphyxia was observed in 187 instances with a mean gestation of 288.8 days. Those who died or had neurologic symptoms had the longest mean gestation, 291 days. Only 5% of the infants dying of unexpected perinatal asphyxia and less than 16% of those with neurologic symptoms were born before their due dates; approximately 64% of the infants with obstetric complications, miscellaneous problems, or no complications or morbidity were born before 280 days. The implications for management of pregnancy at or beyond 280 days are discussed.

Changes in cerebral hemodynamics in preterm infants with and without patent ductus arteriosus.

We compared anterior cerebral pulsatility index (ACPI), anterior cerebral mean flow velocity (ACMFV), common carotid pulsatility index (CPI) and common carotid mean flow velocity (CMFV) in three groups of preterm infants with birthweights less than 1500 grams: 6 without evidence of PDA (group A), 6 with PDA treated with fluid restriction, diuretics or digoxin (group B) and 6 with surgical ligation of PDA (group C). Infants were assessed in three time periods: the first four days of life, five days before surgical ligation and five days post-ligation. Analyses of variance showed no significant differences in the three groups for the four measures in time 1. In time 2, ACPI was 0.61 for group A, 0.58 for group B, 0.78 for group C (p less than 0.01). ACMFV was 9.22 for group A, 7.71 for group B, 6.37 for group C (p less than 0.05). CPI was 0.84 for group A, 0.83 for group B, 0.90 for group C (NS); CMFV was 7.80 for group A, 5.63 for group B, 4.28 for group C (p less than 0.01). In time 3, significant differences (p less than 0.01) were found only for CMFV.

A method for assessing carbohydrate energy absorption and its application to premature infants.

A method was developed for assessing indirectly the fecal excretion of carbohydrate-derived energy. Then, eight healthy premature infants (28 to 32 wk gestation, postnatal age 12 to 30 days) were randomly assigned to receive one of two formulas that differed only in the carbohydrate source: 100% lactose or 50% lactose: 50% glucose polymer (lactose + glucose polymer). Excreta collections were analyzed for total nitrogen, urea nitrogen, ammonia, fat, and total energy. Carbohydrate energy absorption was calculated. The formulas were well tolerated and stool frequency, energy intake, weight gain, and nitrogen balance were not different in the two formula groups. Also, there were no significant intergroup (lactose versus lactose + glucose polymer) differences in the coefficients (%) (x +/- SD) of fat absorption (90 +/- 6 versus 93 +/- 5) or carbohydrate energy absorption (96 +/- 1 versus 95 +/- 3). Thus, net carbohydrate-energy absorption appeared normal in these premature infants who showed no clinical formula intolerance.