The utility of tracheal aspirate cultures in the immediate neonatal period.

OBJECTIVE: Determine the contemporary incidence of pathogenic tracheal aspirate (TA) cultures when obtained within 12 h of birth, and to associate TA culture results with specific clinical conditions that increase the risk of infection. STUDY DESIGN: A retrospective study over a 6-month period of admissions to a single outborn neonatal intensive care unit when a TA sample was collected within 12 h of birth (n=139). RESULT: In total, 9 of 139 (6.5%) TA cultures were positive for pathogenic bacterial growth. Maternal fever (relative risk (RR)=7.7, P<0.04) and clinical chorioamnionitis (RR=6.4, P<0.02) were significantly associated with pathogenic TA culture results. Infants with a pathogenic TA culture had lower white blood cell counts (7,500 vs 13,900 mm(-3), P<0.05) when compared with infants with a negative culture. In eight of the nine patients with pathogenic cultures, either the mother or the infant received antibiotics before TA sample collection. CONCLUSION: Early TA culture is a helpful tool in diagnosing pneumonia, especially in certain clinical scenarios, including maternal fever, clinical chorioamnionitis and leukopenia. Administration of antibiotics before sample collection does not seem to preclude culture growth.

Catheter related bloodstream infection following PICC removal in preterm infants.

OBJECTIVE: Describe the incidence of catheter-related blood stream infection (CRBSI), following removal of peripherally inserted central venous catheters (PICC) in preterm infants. STUDY DESIGN: A retrospective cohort study of infants <29 weeks gestational age with a PICC revealed 101 PICCs placed (2159 PICC days). Patients were hospitalized in a level III Neonatal Intensive Care Unit (NICU) between January 2002 and December 2003. Chi(2) analysis was performed. RESULTS: One infection was detected after the removal of a PICC (1 per 202 days). Ten infants had a CRBSI attributed to a PICC (1 per 216 PICC days). CRBSI during indwelling PICC was associated with increased risk for sepsis evaluation after PICC removal (P<0.05). CONCLUSIONS: The incidence of CRBSI in the 48 h following PICC removal was not different than the incidence of CRBSI while a PICC was in-dwelling. There was no evidence from this study to support antibacterial prophylaxis before PICC removal.

Unsuspected transection of lung by pigtail catheter in a premature infant.

Thoracostomy tubes are commonly required to treat pnuemothoraces in premature infants. Evidence of impalement of the lungs by tube thoracostomy has been seen in autopsy studies. In neonates, there has been described a surprisingly high incidence of lung perforation. The premature lung is thought to be at greater risk for this complication owing to the pliant, thin chest wall, the proximity of vital tissues and the fragility of the lung tissue itself. The modified Fuhrman catheter, or polyurethane pigtail catheter, has been developed for the drainage of pneumothorax in premature infants. In a study of complications of the placement of pigtail catheters, no instance of penetration of the lungs was reported. We report the case of a premature infant with pigtail catheter placement that, at autopsy, was found to have impaled the lung and discuss the incidence of lung injury associated with invasive management of pnuemothoraces.

Subalterns of technopoly: brokering techno-power in academic sociology.

Drawing on responses to a small-scale sensitizing sociological probe of 'technological stratification' in academic sociology, this article considers the role of academic staff delegated to oversee the distribution of information and communications technology resources within their departments between the years 1987-1996. From their recollections as local 'gatekeepers' of the new knowledge technologies, these 'subalterns of Technopoly' perceived themselves as relatively powerless 'techno-power brokers' unable to make a significant difference to the 'technological stratification' they encountered in their working environments in that period.

Lipid intolerance in newborns is associated with hepatic dysfunction but not infection.

OBJECTIVE: To examine the hypothesis that fat intolerance in newborns who receive intravenous lipid is related to both infection and liver dysfunction. DESIGN: Prospective survey. SETTING: Tertiary intensive care nursery. PATIENTS: All newborns who were admitted to the neonatal intensive care unit during a 20-month period and received parenteral lipid for 2 or more weeks were eligible for the study. Of 279 newborns who received parenteral nutrition, 162 met eligibility criteria and form the basis of this report. INTERVENTIONS: None. MAIN OUTCOME MEASURE: Fat intolerance as defined by a serum triglyceride level of 1.69 mmol/L or greater (> or = 150 mg/dL). RESULTS: Triglyceride levels were similar in infected and noninfected patients. Newborns with hypertriglyceridemia were more likely to have liver dysfunction (P < .001) or growth retardation (P < .01), but not infections. Hypertriglyceridemia was approximately twice as likely (P < .05) in newborns with either growth retardation or liver dysfunction. CONCLUSIONS: Liver dysfunction and fetal growth retardation were associated with lipid intolerance in newborns who received intravenous fat. Infection does not appear to be independently associated with hypertriglyceridemia. In the absence of liver dysfunction or growth retardation, there is no a priori reason to limit intravenous lipid use in the presence of infection. Close monitoring of triglyceride levels with adjustments in lipid dose is warranted, especially in small, sick newborns who are at highest risk for hypertriglyceridemia.

Enteral feeding in very-low-birth-weight infants. A comparison of two nasogastric methods.

Nutritional benefits and feeding-related complications were prospectively compared in 53 preterm very-low-birth-weight infants receiving isoenergetic feeding by either the continuous nasogastric (n = 30) or intermittent nasogastric (n = 23) route. Stepwise regression techniques were used to develop models relating feeding-associated factors. Feeding method significantly affected weight gain in infants 1000 to 1249 g birth weight with continuous nasogastric feeding associated with an additional weight gain of 3.6 to 6.1 g/kg/d. No effects of feeding method on changes in occipitofrontal circumference, triceps skin-fold thickness, bilirubin values, or total protein values were demonstrable. There were few major differences between feeding groups on measures of feeding complications. Continuous nasogastric feeding was fairly well tolerated and resulted in improved weight gain when compared with intermittent nasogastric feeding in preterm infants 1000 to 1249 g birth weight.

Broviac catheterization in low birth weight infants: incidence and treatment of associated complications.

Fifty-two Broviac catheters were inserted in 40 preterm and eight term infants for 1733 days of catheter use. Thirty-six (69%) catheters were associated with complications of infection and/or thrombosis, a complication rate of 1/48 catheter days. The patients who developed complications were of a significantly lower gestational age and had a lower mean birth weight when compared with those who developed no complications. The incidence of catheter-related sepsis was 69% in the very low birth weight infants and only 20% in the infants with birth weights over 1500 g. Eighteen of the 26 catheter-associated infections were treated with antibiotics without catheter removal. Successful resolution of the infections with retention of the catheter occurred in 14 of the 18 episodes. Infections with Staphylococcus aureus constituted three of four treatment failures. Urokinase infusion was successful in causing thrombolysis in eight of the nine cases. Broviac catheters in neonates, and especially in preterm infants under 1500 g, are associated with a high incidence of complications. Our experience indicates that some complications can be selectively managed without sacrificing the venous access.

Familial desquamative interstitial pneumonitis occurring in infants.

Desquamative interstitial pneumonitis (DIP) is rare in children. Its cause is unknown. In general, it is of sporadic occurrence. We report 4 infants: 2 sibs in each of 2 separate families, who had DIP. All 4 infants died despite intensive care and immunosuppressive therapy. Our cases, plus one other similar kindred in the literature, confirm the occurrence of familial DIP in infancy. Further, our experience suggests that DIP in these familial cases carries a worse prognosis than that reported in sporadic cases.

Two uncommon radiographic signs of an anterior neonatal pneumothorax. Correlated with clinical finding.

An anterior pneumothorax in a supine neonate is difficult to diagnose. A correlation was sought between radiographic signs of an anterior pneumothorax and clinical data to facilitate the radiographic diagnosis. A total of 817 consecutive admissions to two regional nurseries were reviewed, and infants with pneumothoraces were identified. Nineteen percent of these neonates had anterior pneumothoraces with Medial Stripe and Large Hyperlucent Hemithorax signs observed on the chest radiographs. The Medial Stripe sign was not associated with any distinguishing clinical features that would assist the physician in the interpretation of the radiograph. The Large Hyperlucent Hemithorax sign was noted predominantly on the left side in near-term infants who were breathing spontaneously. It was concluded that there are specific clinical variables associated with a Large Hyperlucent Hemithorax sign of an anterior pneumothorax in a supine neonate.

Acute bronchospasm resembling status asthmaticus during the neonatal period.

Recently, we encountered four neonates who developed severe reversible partial lower airway obstruction. This communication describes their clinical course and the pathogenesis and treatment of acute bronchospasm resembling status asthmaticus and leading to life-threatening respiratory acidosis.

Vancomycin pharmacokinetics in small, seriously ill infants.

Twenty vancomycin pharmacokinetic studies were performed on 17 small infants who were receiving the antibiotic for treatment of documented infections. Fourteen patients were less than or equal to 41 weeks' postconception. In this group there was no statistical difference in mean elimination rate, volume of distribution, or clearance between neonates and infants 4 to 8 weeks of age. However, they had significantly lower clearance and prolonged mean beta-half-life than infants who were 3 to 6 months old (greater than 43 weeks' postconception). Vancomycin clearance was directly related to postconceptional age by linear regression analysis. beta-Half-life was influenced by the weight of the patient, volume of distribution, and gestational age. In view of the interpatient variability observed in the prematurely born infants, pharmacokinetic studies should be performed to determine the appropriate dose and intervals in vancomycin therapy.

Transient respiratory difficulty following cesarian delivery.

57 newborn infants delivered by planned, repeat cesarian section were studied to determine the role of surfactant in transient neonatal respiratory distress. 22.8% of the newborn infants studied had transient tachypnea of the newborn. The mean amniotic fluid lecithin-sphingomyelin ratio (L/S) was 2.8 in normal infants and 2.6 in infants with transient tachypnea. The mean gastric aspirate L/S at the time of delivery was 3.0 in the normal infants and 2.7 in infants with transient tachypnea. There were no statistically significant differences in either amniotic fluid L/S or gastric aspirate L/S. Based on these results we speculate that, despite altered lung mechanics in neonates with transient tachypnea, lung maturity as determined by L/S ratio does not differ from that of normal neonates.

Periodic breathing in infants with histories of prolonged apnea.

Periodic breathing (PB) during sleep was investigated in two groups of full-term infants with histories of apnea that were terminated by resuscitation. One group of infants had been reported to be asleep whereas the other group had been reported to be awake when apnea was noted. Electrophysiologic sleep recordings were made after the apneic incident. The infants with histories of prolonged apnea while asleep exhibited more PB during recorded sleep than infants with histories of apnea while awake. Increased PB during sleep in full-term infants, therefore, may not be associated with all prolonged apneic episodes in infants but may be specifically associated with those episodes that occur during sleep.

Gastroesophageal reflux in infants: relation to apnea.

The temporal relationship between apnea and gastroesophageal reflux was examined in 14 infants with abnormal GER scores and histories of prolonged apnea. Simultaneous polysomnographic and intraesophageal pH recordings were performed for each infant. GER episodes were compared to control segments of the recording (without GER) for frequency and type of apnea. Apnea was equally likely to occur during the control segments as during the GER episodes. Brief obstructive apneic episodes were more common during the onset of GER episodes than the onset of control segments. GER duration appeared prolonged during sleep. GER and apnea were not temporally related in the majority of instances, and may be two manifestations of a more general developmental delay.