Identification of optimal lung volume during high-frequency oscillatory ventilation using respiratory inductive plethysmography.

OBJECTIVES: First, to define the relationships between critical opening and closing pressures and oxygenating efficiency, and second, to address whether respiratory inductive plethysmography (RIP) could be used to monitor changes in thoracic volume that follow changes in mean airway pressure during high- frequency oscillatory ventilation (HFOV). DESIGN: Prospective, interventional animal study. SETTING: University research laboratory. SUBJECTS: Five anesthetized, paralyzed, and ventilated pigs. INTERVENTIONS: The animals were ventilated by using HFOV after lung injury. Pre- and post-HFOV pressure-volume curves were obtained by supersyringe. A pressure-volume curve was constructed during HFOV as mean airway pressure was increased from 10 to 40 cm H(2)O and then weaned back down to the minimum sustainable. Hemodynamic and oxygenation data were obtained at each data point. MEASUREMENTS AND MAIN RESULTS: RIP-derived thoracic volumes correlated with known lung volumes during supersyringe (r(2) =.78, p <.00001). During HFOV, three of five animals had an identifiable critical opening pressure of the lung, and four of five had an identifiable critical closing pressure. No consistent relationship between critical opening and critical closing pressures was observed. During the weaning phase of HFOV, a relative decrease in RIP-measured volume of >10% predicted the decrease in oxygenation associated with reaching the critical closing pressure. CONCLUSIONS: The ability of RIP to detect optimal lung volume during the weaning of mean airway pressure may allow clinicians to more directly monitor lung volume changes during HFOV and use the lowest possible airway pressures after lung recruitment.

The Touchpoints Pediatric Asthma Program.

The Brazelton Touchpoints Center at the Child Development Unit, Children's Hospital, Boston, MA, designed a program intended to change the way asthma is managed in medical offices across the United States. This program was recently implemented at five pediatric asthma practices in the Chicago area where asthma prevalence is alarmingly high.

The psychological status at school age of children conceived by in-vitro fertilization.

This study assessed the behavioural and psychological profiles of children conceived by in-vitro fertilization (IVF) who are now at school age. A total of 743 IVF children born at one institution and now of school age, over 4 years old, were surveyed with Achenbach questionnaires. Follow-up telephone interviews were conducted with non-responders. The results from the study group were compared to the questionnaire control group using one-tailed t-test with statistical significance set less than 0.05. There was an 84% overall response rate. Sixty-seven per cent returned questionnaires. An additional 17% completed a telephone interview. The study group had no statistically significant increase in the rate of behavioural or psychological problems compared with the control group. There were no statistically significant differences within the study group related to sex or to multiple gestation IVF births. This large group of school-age IVF children has normal psychological development with no identified adverse effect of their status as IVF children. Determining the role, if any, of IVF in the very small number of children with behavioural and psychological problems will require additional study.

Specificity of preventative pediatric intervention effects in early infancy.

The efficacy of two contrasting short term preventative interventions administered to a heterogeneous sample of new mothers during the perinatal period was evaluated. The first was infant-centered and used the Brazelton Neonatal Behavioral Assessment Scale (NBAS) as a method of highlighting newborn behavior to new mothers. The second was mother-centered and consisted of an in-depth interview focused on the mothers' concerns about parenting. Mothers were randomized into groups and were administered intervention by experienced clinicians at 3 days in the hospital and again at 14 and 30 days at home. Effects of intervention on maternal reports of parenting stress, mother-infant interactive behavior, and infant developmental quotient were evaluated at 4 months infant age. It was hypothesized that participation in the infant-centered intervention would be related to more positive maternal and infant outcomes at 4 months. It was also expected that the impact of each intervention would be moderated by differences in maternal and infant risk and parity. Hierarchical multiple regressions controlling for risk and parity yielded no significant main effects of intervention at 4 months. However, significant interactions of intervention with parity and risk were observed, indicating that intervention was beneficial for specific groups of mothers. These data suggest that early intervention should be tailored to the needs of individual groups of mothers.

Neonatal-onset propionic acidemia: neurologic and developmental profiles, and implications for management.

OBJECTIVES: To document the clinical and neurodevelopmental profiles of a cohort of patients with neonatal-onset propionic acidemia and to determine the efficacy of current therapy with respect to outcome. METHOD: The clinical, neurologic, and developmental status of six patients was prospectively evaluated during a 15-month period. Previous clinical and biochemical data were ascertained from hospital records to determine longitudinal nutritional status, number of episodes of hyperammonemia with ketoacidosis, and developmental performance with respect to age. RESULTS: No deaths resulted from propionic acidemia since the identification of the oldest patient in the series in 1980. Therapeutic intervention (e.g., gastrostomy tube feeding) resulted in improved nutritional status and possibly contributed to improved survival. All children had hypotonia, resulting in a significant effect on motor development; however, focal neurologic deficits and evidence of movement or seizure disorder were absent. Mild cortical atrophy was evident on cranial magnetic resonance imaging in four patients. All children, including two patients with no significant episodes of hyperammonemia and normal growth since the neonatal period, had a mild to moderate degree of intellectual impairment. CONCLUSIONS: The results of our study suggest that current therapy for neonatal-onset propionic acidemia is associated with improved survival and nutritional status, and an absence of focal neurologic deficits. However, hypotonia and cognitive delay were still present, even in children with "optimal" metabolic control. Additional therapeutic advances are required to improve the developmental and cognitive outcome.

Working with families. Opportunities for early intervention.

The birth or arrival of a baby is a defining event for families. Most infants progress through predictable, yet individual, patterns of development. All families want the opportunity to optimize their children's futures, yet each spurt of development is a transition that can stress the child and the entire family system. These biobehavioral shifts, or "touchpoints," provide opportunities for the pediatrician to help the family understand, adapt, enhance, and promote the child's outcome. This family level approach serves as a form of anticipatory guidance that helps both parent and child successfully manage the challenging phases of development: motor, cognitive, social, and emotional. The "touchpoints" concept can be adapted for the pediatrician to help older children and their families.

The effects of maternal epidural anesthesia on neonatal behavior during the first month.

The effects of maternal epidural anesthesia with bupivacaine on the infant's performance on the Neonatal Behavioral Assessment Scale (NBAS) over the first month of life were examined. 20 non-medicated infants were matched for biomedical and demographic variables with 20 infants delivered with bupivacaine epidural anesthesia. The NBAS was administered on days 1, 3, 7 and 28. The epidural group showed poorer performance on the orientation and motor clusters during the first month of life. Epidural mothers reported spending less time with their infants while in the hospital; post hoc analyses showed that they had longer labor, more forceps deliveries and a greater amount of oxytocin. Controlling for the effects of these medical variables, a dose effect was found for the mean orientation and motor cluster scores. The results are discussed in terms of possible effects of the infant's early disorganization on the mother-infant interaction.

Saving the bathwater.

This article presents an account of the development and use of the Neonatal Behavioral Assessment Scale (NBAS) over the past 15 years. It deals with both the formal and informal ways in which administering the NBAS has increased our understanding of the forces for development in the newborn, of states of consciousness in the infant, of the potential for predicting from one point in development to the next, and of a clinician's opportunities to share information with parents and to participate in the enterprise of parenting. It draws attention to the value of the qualitative insights that are gained by investigators, alongside the more quantitative fruits of a research endeavor.