Continuous intravenous morphine infusion in postoperative newborn infants.

The efficacy and safety of morphine sulfate was evaluated in 20 neonates requiring surgery. Following surgery, each subject received an intravenous morphine loading dose (50 micrograms/kg) followed by a continuous infusion (15 micrograms/kg/hr) for a minimum of 24 hours. Heart rate, respiratory rate, and blood pressure were frequently monitored during therapy. Blood samples were obtained following surgery and during and after morphine therapy for analysis of serum morphine and beta-endorphin content. A 12-hour urine collection was obtained 12 hours following the start of the constant morphine infusion for analysis of morphine content. The mean (+/- SD) duration of morphine infusion was 34 +/- 15 hours and a steady-rate serum morphine concentration was 39 +/- 23 ng/ml. The respective serum morphine half-life, elimination rate, and volume of distribution were 6.6 +/- 2.9 hr, 0.126 +/- 0.056 hr-1, and 5.0 +/- 6.8 liters/kg. The mean percentage of unchanged morphine recovered in the urine was 39 +/- 19 of the dose administered over 12 hours. A significant reduction in serum beta-endorphin content was observed following the onset of morphine therapy. No adverse reports were noted that could be attributed to morphine therapy. Continuous morphine therapy appears to be effective in controlling neonatal postoperative pain, as suggested by subjective nursing observations and decreased serum beta-endorphin content.

Large postnatally acquired porencephalic cysts: unexpected developmental outcomes.

To determine the neurodevelopmental outcome for infants with posthemorrhagic intraparenchymal cysts, we reviewed retrospectively clinical, ultrasonographic, and developmental features in 16 affected children. At a mean follow-up age of 33 months, five subjects had normal cognitive outcomes (developmental quotient [DQ] or IQ greater than 83), nine had borderline to mild deficits (DQ or IQ, 52 to 83), but only three had moderate to severe deficits (DQ or IQ less than 52). Spastic cerebral palsy was present in 13 (81%); only one child (6%) had a chronic seizure disorder requiring medication. Cognitively normal children were less likely to have had neonatal seizures (P less than .05) and tended to have more localized cysts. Otherwise, we found no relationship between outcome and neonatal clinical or laboratory findings. Overall, these results suggest that although motor deficits are common in infants with severe intraventricular hemorrhage and porencephalic cysts, cognitive outcomes may be more favorable than has been suspected previously.

Localized intestinal perforation following intravenous indomethacin for patent ductus arteriosus.

We describe a very low birth weight infant given intravenous indomethacin for a symptomatic patent ductus arteriosus who subsequently developed a gastrointestinal perforation. Although this is a well-known complication of enteral preparations, it has not been described with the intravenous form. Various mechanisms described in the literature by which the intravenous route of administration may compromise the bowel are presented. Although rare, gastrointestinal complications with intravenous indomethacin may become more prevalent with its increased use.

Respiratory illnesses in survivors of infant respiratory distress syndrome.

This prospective study examined the frequency and severity of respiratory illnesses in survivors of preterm birth compared with those in full-term infants. Although preterm infants did not demonstrate an inherent risk of subsequent respiratory illness when compared with full-term infants, earlier and more severe lower respiratory illnesses were observed among survivors of idiopathic respiratory distress syndrome (RDS). Infants who survived RDS but who developed residual lung disease had a greater risk of both more frequent and more severe subsequent lower respiratory illnesses than did RDS survivors who did not have persistent roentgenographic changes. We suggest that the risk of increased respiratory illness in these infants was a consequence of residual pulmonary abnormalities apparent on the chest roentgenogram at discharge from the nursery. Agents associated with respiratory illnesses were similar in all groups of study patients.

Current therapy of acute bacterial meningitis in children: Part II.

Despite many advances in the past decade in the development of new antimicrobials, acute bacterial meningitis continues to have significant morbidity and mortality in infants and children. Regardless of the effectiveness of the antibiotic preparations, future improvements in outcome is most likely to occur because of more rapid diagnosis and initiation of therapy. The standard penicillins, chloramphenicol, and the aminoglycosides continue to hold an important place in treatment. The recent introduction of new extended spectrum penicillins, including piperacillin and mezlocillin, in addition to the development of the third generation cephalosporins, have expanded alternatives for treating bacterial meningitis. The most appropriate and effective antibiotic or combination of antibiotics must first be selected; thereafter, its use must be monitore to identify its beneficial effects as well as possible adverse effects.

Head ultrasound screening in premature neonates weighing more than 1,500 g at birth.

During a 14-month period, 112 consecutively born neonates with a birth weight between 1,501 and 2,000 g were screened by cranial ultrasonography. Nineteen patients (17%) had abnormal scans. Of these abnormalities, 14 (13%) were germinal matrix hemorrhage and/or intraventricular hemorrhage. Although the incidence of hemorrhage in these larger premature neonates is less than that which has been described in neonates with a birth weight less than 1,500 g, the severity of the hemorrhage, mortality (21%), morbidity, and outcome were similar to those seen in smaller neonates. More than half of the hemorrhages identified were severe, ie, grades III and IV. The clinical picture in these neonates was striking in that each suffered severe birth asphyxia and/or required ventilation shortly after birth. Therefore, screening all larger premature neonates is probably not warranted and selective screening will be adequate to identify those neonates who need intervention or would benefit from developmental follow-up.

Respiratory and gastrointestinal illnesses in breast- and formula-fed infants.

Ten breast-fed infants, each paired with a formula-fed infant, were evaluated prospectively from birth to the age of 112 days to identify respiratory and gastrointestinal (GI) illnesses and microorganisms associated with respiratory tract infections. The infants were matched by age and sex. More GI illnesses occurred among the formula-fed infants. Although the breast-fed infants had less exposure to tobacco smoke in the home and less exposure to other children in day-care settings, there was no suggestion of a decrease in the frequency of respiratory illness during the first four months.

CSF lactate levels in neonates. Effect of asphyxia, gestational age, and postnatal age.

During a six-month period, lactate measurements were performed on all samples of CSF obtained by lumbar puncture from infants of varying gestational ages between birth and 32 days of age. The normal levels of lactate in the CSF of newborns were demonstrated to be higher than those previously reported in older children or adults. A steady decrease in CSF lactate levels was demonstrated as postnatal age increased, so that after the first ten days of life, CSF lactate levels were within the range reported for older children and adults. We could not demonstrate that neonatal asphyxia or gestational age significantly altered these values.

Developmental and neurologic sequelae of neonatal hyperviscosity syndrome.

One hundred eleven consecutive infants with neonatal hyperviscosity were identified by screening all newborns for polycythemia in an 18-month period. These polycythemic infants were matched with non-polycythemic newborns for birth weight, gestational age, Apgar scores, and sex. Maternal, intrapartum, and neonatal data were analyzed for associated morbidity. Maternal preeclampsia was more common among the hyperviscous patients than among control subjects. Hypoglycemia was also significantly increased among the hyperviscous patients. Follow-up studies at 1 to 3 years of age revealed a significantly higher incidence (38% vs 11%) of motor and neurologic abnormalities in the infants with neonatal hyperviscosity. The data suggested that concurrent hypoglycemia increased the risk of a poor outcome in hyperviscous infants inasmuch as 55% of infants with both characteristics were abnormal at follow-up. This, however, was not significantly different from the outcome of infants with hyperviscosity alone (P greater than .05 but less than .1). Further studies will be needed to confirm or deny this relationship.

Effects of magnesium sulfate treatment on perinatal calcium metabolism. II. Neonatal responses.

To evaluate the effects of maternal magnesium sulfate treatment on neonatal magnesium and calcium homeostasis, the authors studied 23 term neonates whose mothers had received intravenous magnesium sulfate for pre-eclampsia and compared them with 14 control neonates. Total and ionized calcium, magnesium, phosphorus, and albumin were measured in maternal and umbilical blood; total calcium, magnesium, phosphorus, and albumin were measured serially in the newborn infants. Magnesium levels were higher in treated than in control infants in umbilical venous and arterial blood samples and in the neonatal blood samples 2, 12, and 24 hours after delivery. However, at 48 hours and beyond there was no difference in serum magnesium levels between treated infants and controls. Calcium levels were not significantly different in treated versus control subjects in umbilical blood or in any neonatal samples. There was no correlation between the maternal magnesium concentration at delivery and the levels of calcium in umbilical or neonatal blood. These data indicate that maternal magnesium sulfate therapy does not cause neonatal hypocalcemia and that the induced neonatal hypermagnesemia is resolved within the first 48 hours of life.

Endocarditis in the newborn.

Three cases of endocarditis confirmed at autopsy were identified in an intensive care nursery during an eight-month period. Echocardiography demonstrated abnormal echoes in the region of the mitral valve in one infant and the tricuspid valve in the other two infants. Both the diverse clinical manifestations of bacterial and nonbacterial endocarditis and the value of echocardiography in the establishment of an antemortem diagnosis are discussed. This previously unusual entity seems to be occurring with greater frequency in neonatal intensive care units that provide vigorous efforts to support severely ill infants.

The neonatal neurobehavioral effects of bupivacaine, mepivacaine, and 2-chloroprocaine used for pudendal block.

The neonatal neurobehavioral effects of bupivacaine, mepivacaine, and 2-chloroprocaine used in random sequence for pudendal block anesthesia were studied. The neurobehavioral status of 54 infants was studied 4 and 24 hours after delivery. Except for a significant difference in the responses to pinprick, there was no significant effect of any of these agents on infant neurobehavior, and no differences were found among the agents themselves. Mean mepivacaine levels in neonatal capillary blood at 4 hours of age were low (0.10 +/- .02 microgram/ml) compared with those in previous studies because of the short interval between maternal injection and delivery (13 +/- 3 min). Bupivacaine gave higher neonatal capillary blood levels (0.15 microgram/ml at 4 hours of age) than previously reported, but the drug still produced no detectable neonatal neurobehavioral effects.

Epidural anesthesia with bupivacaine for Cesarean section: neonatal blood levels and neurobehavioral responses.

A recent study found no neurobehavioral change in infants whose mothers received bupivacaine epidural anesthesia (112 +/- 7 mg) for labor and vaginal delivery. The present study was undertaken to examine the possibility that the larger doses of bupivicaine necessary for cesarean section might cause neurobehavioral changes in the neonate. Ten infants delivered by cesarean section with bupivacaine epidural anesthesia (168 +/- 7 mg) was assessed by Scanlon's neonatal neurobehavioral examination. They were compared in a prospective randomized study with a control group of ten infants delivered with tetracaine spinal anesthesia. In the experimental group bupivacaine was detectable in umbilical arterial blood (.17 +/- .07 microgram/ml), umbilical venous blood (.21 +/- .09 microgram/ml), and neonatal blood samples at 4 hours of age (.04 +/- .04 microgram/ml). By 24 hours of age bupivacaine was no longer detectable in newborn blood samples. Infants in the experimental group were indistinguishable from control infants in terms of their motor organization, responsiveness to external stimuli, and habituation to repetitive stimuli. Detectable neurobehavioral effects were absent despite the fact that 1.5 times the dose of bupivacaine used for labor and vaginal delivery was employed in this study.

The silent ductus arteriosus.

Preterm infants at risk of developing a patent ductus arteriosus were followed sequentially by physical examination, echocardiographic determinations of the LA/AO ratio, and chest roentgenograms. The results show that a significant number of infants who have no clinical signs or symptoms of a PDA have large left-to-right shunts. The presence of this shunt was suggested by acute increase in left atrial size by ECHO determination and confirmed by retrograde single-film aortography. Clinical signs and symptoms often developed several days after documentation of the left-to-right shunt.

Thick blood syndrome.

Twenty cases of hyperviscosity were studied prospectively to determine the presence and incidence of radiological findings and whether or not exchange transfusion had an appreciable effect on these findings. Serial chest radiographs revealed increased pulmonary vascularity, hyperaeration, and mild, bilateral alveolar infiltrates (perihilar and/or lower lobe). Ten patients were treated with partial plasma exchange transfusions which resulted in improvement of radiological findings. Hyperviscosity is more common than previously recognized. This entity may have profound significance as a potentially treatable cause of central nervous system damage in the neonate.