A comparison of albumin-bolus therapy versus normal saline-bolus therapy for hypotension in neonates.

OBJECTIVE: We compared responses to bolus infusion of 5% albumin (ALB) or normal saline (NS) for hypotension in neonates. STUDY DESIGN: Hypotensive infants were given 10 ml kg(-1) of NS or ALB. A second bolus was given for persistent hypotension. Dopamine therapy was started for hypotension after the second bolus. The primary response was increase in arterial blood pressure toward normal range 1 h postinfusion. Secondary measures included duration of normotension, meeting criteria for second bolus, meeting criteria for vasopressor support and cost comparison. RESULT: Those receiving ALB (N=49 ALB and 52 NS) were more likely to achieve a normotensive state (ALB=57.1%, NS=32.1% P=0.01) 1 h following the initial bolus therapy. Subsequently, the NS group was also more likely to qualify for vasopressor infusion (ALB=24.5%, NS=44.2% P=0.02). Overall cost for either therapy was equivalent. CONCLUSION: In hypotensive neonates, ALB results in a greater likelihood of achieving normotension and decreased subsequent use of vasopressors when compared to NS.

Assessment of motor development in very low birth weight infants.

OBJECTIVE: The purpose of the current investigation was to describe the fine- and gross-motor acquisitions of very low birth weight (VLBW) infants during their first 12 months without imposing traditional assessment assumptions. STUDY DESIGN: A nonrandomized, prospective study was used for a sample consisting of 89 VLBW infants whose motor development was assessed neonatally and at 4, 8, and 12 months chronological age. Fine- and gross-motor assessment items were selected and adapted from three standardized assessment instruments. RESULTS: The fine- and gross-motor systems of development appeared to be relatively independent of one another before the 8-month assessment. Thus, early fine-motor control appeared to develop almost to the exclusion of gross-motor progress. Once fine-motor control was established by 8 months, numerous gross-motor milestones followed and were present at 12 months chronological age. CONCLUSION: Current and previous data continue to define a developmental picture in which VLBW and fullterm infants achieve the same fine- and gross-motor milestones; however, the developmental pathways whereby milestones are achieved, during at least the first 12 months, appear to be different. Accordingly, applying instruments standardized on fullterm infants to the assessment of VLBW babies may not be serving us well on a number of different issues.

Parents' perceptions of medical diagnoses and related issues for their high-risk infants.

INTRODUCTION: The objectives of this study were (a) to compare maternal and paternal perceptions of infant medical diagnoses with hospital-chart diagnoses, (b) to examine whether parental perceptions of infant medical condition (using three variables) were related to eight other parental perceptions, and (c) to determine what medical diagnoses were associated with parental expectations that neonatal diagnoses were having current effects of would have future effects on their infant. METHOD: With a questionnaire format 76 parents reported information about medical diagnoses and their perceptions about eight other issues for their infants who had been hospitalized in an NICU. RESULTS: Parents reported approximately 62% of the medical diagnoses for their infants during NICU hospitalization; these significantly differed from hospital-chart diagnoses. Parents who reported current or future effects of neonatal diagnoses also (a) had fears for their infants while in the hospital or currently, (b) perceived prematurity as having current or future effects, (c) reported restrictions for their infants caused by neonatal diagnoses, and (d) gave less optimal ratings for their infants' current health status. Parents' perceptions of current or future effects of neonatal diagnoses appeared to be inaccurate given the actual diagnoses for their infants. DISCUSSION: The underreporting of diagnoses by parents raises several issues as to how accurately parents are perceiving their infants. Parents who perceived continued effects of neonatal diagnoses also had less optimal perceptions of other related issues. Parent's perceptions of continued effects of neonatal diagnoses appeared to be unwarranted with respect to the actual diagnoses assigned to their infants.

Nosocomial sepsis in the neonatal intensive care unit.

OBJECTIVE: To evaluate the risk factors for nosocomial sepsis among infants hospitalized in 23 neonatal intensive care units. METHODS: Risk factors for nosocomial sepsis among 5760 admissions are analyzed by birth weight groups, <1 kg, 1 to 1.5 kg, and >1.5 kg. A Cox hazard regression model was used to evaluate further detail in the two lower weight groups. RESULTS: Use of corticosteroids had no effect on the incidence of nosocomial sepsis in the two lower weight categories although it was significant among the >1.5 kg infants. In a simple Cox model, significant risk factors included lowest birth weight category, ventilatory support, and presence of a central venous catheter. The complex Cox model revealed that an increase in total days of presence of central arterial catheter, use of antibiotics, and ventilatory support were significant but that total days of presence of a central venous catheter was not. A model for Candida sepsis revealed as a risk factor an increase in total days of use of antibiotics before infection. CONCLUSIONS: The risk for infection associated with presence of a central venous catheter is the same for each day of exposure (i.e., the same risk on day 5 of presence of the line as on day 30), but the risk associated with ventilatory support increases over time. Candida sepsis is associated with prolonged antibiotic use before the first episode of nosocomial sepsis and not with birth weight group.

The plantar response in normal newborn infants.

The neonatal plantar response has been reported as extensor in 90% of newborns and flexor in 93% of newborns, leading to uncertainty about its reliability and significance. To determine the normal neonatal plantar response we examined 349 healthy newborn infants, > 32 weeks gestation within 24 hours of birth. A supramaximal noxious stimulus was applied in a standardized manner to the lateral plantar surface of each foot. The plantar response was extensor in 90%, equivocal in 7%, and flexor in 3%. With proper physiologic technique, the normal neonatal plantar response is extensor.

Longitudinal head growth in developmentally normal preterm infants.

OBJECTIVE: To determine growth in head circumference from birth to 18 months of age in normal infants with low birth weight. METHODS: Healthy, appropriate-for-gestational-age, singleton, white infants weighing less than or equal to 2500 g at birth and with normal development at 18 months of age were included in this study. Serial measurements of head circumference (corrected for gestational age) from 450 eligible infants were compared with reference data for head circumference. RESULTS: Longitudinal measurements of head circumference for infants weighing more than 1000 g at birth were similar to reference data for term infants. Head measurements for infants weighing less than or equal to 1000 g at birth were notably smaller than the measurements in the reference data. A cubic spline curve drawn through the head circumference measurements between birth and age 18 months (corrected for gestational age) for infants weighing less than or equal to 1000 g at birth was significantly (P < .001) below the curve for infants weighing more than 1000 g at birth. At age 18 months, the mean difference in head circumference between the group weighing less than or equal to 1000 g at birth and the weights in the reference data was 1.6 cm (P < .01). (Data were analyzed with Wilcoxon's signed rank test.) CONCLUSIONS: These data show that head circumference grids are appropriate for observing head growth in infants with a birth weight more than 1000 g. However, head circumference growth for normal infants with birth weight less than or equal to 1000 g does not "catch up" with that of larger premature infants or term infants.

Relationships between parental ratings of infant temperament, risk status, and delivery method.

One hundred forty parents rated the temperament of their infants between the ages of 4 and 8 months. Analyses of the data examined the relationships between temperament and infant risk status (high or low), delivery method (vaginal or cesarean section), and the combined effects of infant risk status and delivery method. Although high-risk and low-risk infants were similar on the easy-difficult profile ratings of the revised infant temperament questionnaire, high-risk infants were rated more adaptable and more positive in mood than were the low-risk infants. Low-risk infants delivered by cesarean section were rated less optimally on three of the temperament factor scores, including withdrawal, mood, and adaptability. Interpretations of these findings are discussed and suggestions are offered for nurse practitioners and their provision of pediatric care to infants and their families.

Contribution of low-molecular-weight compounds to the fecal excretion of carbohydrate energy in premature infants.

It was hypothesized that low-molecular-weight products of carbohydrate fermentation would contribute only a small percentage to the total fecal excretion of nonfat, nonnitrogenous energy (carbohydrate energy) in premature infants. Infants born at 28-32 weeks' gestation who were 2-4 weeks of age were randomized to receive a formula with lactose as the sole carbohydrate (n = 7) or the same formula with 50% of the carbohydrate as glucose polymer (n = 8). The percent contribution (X +/- SD) to total carbohydrate energy of sugars (glucose, galactose, lactose, glucose polymer), short-chain fatty acids (acetate, propionate, butyrate, isobutyrate, valerate, and isovalerate), and D- and L-lactate was 9.4% +/- 2.9% for the 15 subjects and was not significantly different between groups. The percent contribution of all four sugars was 5.8% +/- 1.7% and did not differ between the two groups. Doubling the lactose intake resulted in significant increases in fecal excretion (kilocalories per kilogram per day) of acetate (77% increase; P = 0.03), total short-chain fatty acids (54%; P = 0.04), and galactose (188%; P = 0.03). These data suggest that as much as 90% of fecal carbohydrate energy may be in the form of large-molecular-weight compounds, presumably bacterial in origin.

Joint range of motion development in premature infants.

: The purpose of this study was to document joint range of motion of premature, very low birthweight infants and to describe developmental changes in joint range in the first year of life. The relationship between a group of three central nervous system complications and obtained range of motion was investigated. A longitudinal descriptive design was used documenting joint range of motion values over the first year of life in 65 premature, very low birthweight infants. Joint range of motion values were obtained using a plastic goniometer. Measures were based on an adaptation of the Amiel-Tison assessment. Infants were tested at the time of hospital discharge, and at 4, 8, and 12 months chronological age. The obtained values were summarized through descriptive statistical methods. Longitudinal trends in the sample demonstrated changes in joint range of motion over time. However, the preterm infants never displayed the high amount of flexion characteristic of full-term babies. The premature infants in the present study demonstrated more hip extension as they approached term conceptional age than previously reported values for full-term newborns. The present sample also had more elbow extension and less ankle dorsiflexion in comparison with previously reported findings for term infants. These findings may have developmental implications for a divergent course of neuromotor development in premature infants.

Daily sequential changes in plasma atrial natriuretic factor concentrations in mechanically ventilated low-birth-weight infants. Effect of surfactant replacement.

Plasma atrial natriuretic factor (ANF) concentrations are elevated in mechanically ventilated infants. To test the hypothesis that changes in pulmonary compliance affect ANF concentration, we measured plasma ANF concentrations sequentially in low-birth-weight, ventilated infants who either received surfactant replacement or placebo on day 1. ANF concentrations were elevated as compared to adult controls on day 1 and increased significantly on days 2 and 3 before declining. Day 5 concentrations were not different from day 1. Several infants had ANF concentrations greater than 1,280 pg/ml on days 2-4. There were no significant differences in ANF concentrations between surfactant-treated and non-treated infants on any day. ANF concentrations increased in parallel with changes in salt and water balance, but no significant relationships were apparent between absolute ANF concentrations and parameters of salt and water balance. The results suggest that ANF secretion is elevated in infants with pulmonary disease. While the temporal relationship between the initial rise in ANF concentration and increase in salt and water excretion suggest that ANF is involved in this diuresis, the role it may play is unclear from the present data.

Physical characteristics of infant endotracheal tubes.

A change in the incidence of post-intubation complications in infants was the stimulus for the evaluation of the deformability of two brands of endotracheal tubes. The stiffness of each tube was evaluated at room and body conditions in the longitudinal axis of the tubes as well as a cross sectional plan. Shiley brand endotracheal tubes sizes 2.5 to 4.0 were less deformable than Portex brand of the same sizes.

Dietary carbohydrate assimilation in the premature infant: evidence for a nutritionally significant bacterial ecosystem in the colon.

Carbohydrate energy absorption and breath hydrogen concentration were measured in 12 premature infants 28-32 wk gestational age and 2-4 wk postnatal age. Each of two groups of six infants were randomly assigned to receive one of two formulas that differed only in carbohydrate source: 100% lactose (LAC) or 50% lactose: 50% glucose polymer (LAC + GP). In 11 infants the peak breath hydrogen concentration suggested extensive colonic fermentation (range 44-239 ppm/5% CO2 or 44-239 microL/L per 50 mL/L CO2). An approximate 100% increase in lactose intake in the LAC group was associated with a similar increase in breath hydrogen concentration at 30, 60, and 120 min. None of the infants exhibited diarrhea or vomiting or developed delayed gastric emptying. Carbohydrate energy absorption (mean +/- SD) was, respectively, 86 +/- 5% and 91 +/- 3% in the LAC and the LAC + GP groups (p greater than 0.05). Thus, colonic bacterial fermentation may be critical to energy balance and to the prevention of osmotic diarrhea in premature infants fed lactose.

Radiation safety and protection of neonates in radiological examinations.

Radiation reduction methods in neonatal radiographic examinations are discussed. Studies performed on radiation exposures to the neonates, scattered radiation level, exposure to the nursery personnel, effectiveness of the various shielding methods, uniformity of the x-ray field, heel effect, and skin exposure estimation are described. In summary, recommendations for exposure reduction based on our experimental findings as well as on the ALARA concept of radiation safety are provided.

Effects in premature infants of normalizing breath H2 concentrations with CO2: increased H2 concentration and reduced interaliquot variation.

Interval sampling of expired breath samples from the anterior nares is a feasible and noninvasive method for detecting elevated breath H2 and thus colonic carbohydrate fermentation, especially in nontherapeutic research studies of healthy premature infants. However, there may be a risk of falsely low breath H2 concentration and an unacceptable experimental error due to contamination with room air as well as with dead space air. We studied ten premature infants (28-32 week gestational age and 2-4 weeks postnatal age) who were receiving either a proprietary formula containing equal proportions of lactose and glucose polymer, or a similar formula in which lactose was the sole carbohydrate. In 70 breath samples (obtained 30-180 min after feeding) we assessed the coefficient of variation in breath hydrogen concentration among three aliquots obtained over a 3-5 min interval. Breath was collected from the anterior nares. The interaliquot coefficient of variation averaged 11% when expressed as parts per million per 5% CO2, compared to 19% when expressed as parts per million (Wilcoxon, p less than 0.001). Mean breath hydrogen concentration at each time period using the former method (parts per million per 5% CO2) was about 100% higher than when using the latter method. Although ventilation rate can alter alveolar CO2, normalizing for CO2 concentration reduces a major source of experimental error.

Parental recall of infant medical complications and its relationship to delivery method and education level.

Since relatively little is known as to why parents find it difficult to recognize when their high-risk infant ceases to be ill, this investigation examined parental reports of infant complications and the relationship these reports had with parental education level and method of delivery. Using a questionnaire format, 60 parents reported complications their infants experienced during NICU (neonatal intensive care unit) hospitalization. Maternal and paternal reports were comparable, although both significantly differed from actual diagnoses; parents underreported their infant's complications. Reported complications were not related to parental education level but were associated with method of delivery. Parents of Caesarean-section (C-section) infants identified a significantly smaller percentage of complications than did parents of vaginally delivered babies. It is suggested that (1) medical caregivers have the potential for helping parents more fully comprehend infant complications, (2) supplemental communication methods may be necessary for the task in (1), and (3) information communicated to parents may need to incorporate the current findings about parental education level and delivery method.

Gastroesophageal reflux and the premature infant.

Gastroesophageal reflux (GER) is a well-recognized problem in infants and children. Only scant mention of the premature infant with GER can be found in the literature. Of 760 preterm infants admitted to the NICU between 1980 and 1984, 22 had documented GER. These infants all underwent medical management including upright positioning, small frequent feeds, and often, nasojejunal feedings. Seventeen babies did not respond to medical management and underwent surgical therapy to control the reflux. Of the 17 babies requiring fundoplication, 15 had been initially intubated for treatment of respiratory distress syndrome. Eight of these 15 were extubated in less than 25 days and were improving until they exhibited sudden episodes of deteriorating pulmonary status requiring reintubation. The other seven intubated patients developed striking bronchopulmonary dysplasia (BPD) in the first month and required prolonged ventilatory support. Pulmonary deterioration, failure to grow, and refusal to eat became the herald of GER in these infants. Fundoplication dramatically improved the pulmonary status in all but one infant. Three late deaths can be attributed to cor pulmonale and pulmonary failure. BPD was striking predisposing factor for severe GER in these premature infants. In the total premature population without BDP only 8 of 684 (1.2%) had GER with five responding to medical management and three others undergoing fundoplication for apnea-bradycardia spells. Fourteen of the 76 infants with BPD (18.4%) had significant GER and all required surgical management for control of symptoms. Premature infants who develop deteriorating pulmonary function, poor growth, and/or refusal to eat should be evaluated for GER.