Impact of skin to skin care, prone and supine positioning on cardiorespiratory parameters and thermoregulation in premature infants.

BACKGROUND: Skin to skin care (SSC), prone (PP) and supine (SP) positions are standard positions in daily care for premature infants. Their influence on cardiorespiratory parameters and thermoregulation is discussed controversially. OBJECTIVES: We compared SSC with PP, the recommended position for preterm infants, and SP, the safest position for term infants, and tested the hypothesis that SSC has no impact on cardiorespiratory parameters and thermoregulation. METHODS: In 18 spontaneously breathing premature infants [median gestational 28 weeks (24-32); chronological age 36 days (7-64), and weight 1,543 g (750-2,100)], heart and respiratory rate, breathing pattern, episodes of desaturation (<85 but >or=80 and <80%), oxygen saturation and rectal temperature were analyzed with polygraphy (Alice 3(R) and 3.5(R)) in a 6-hour measuring cycle of three subsequent series (120 min each in SP, SSC and PP) and compared (Wilcoxon test). RESULTS: During SSC, we found no increase in apneic attacks and bradycardic episodes and no difference in respiratory rate, breathing pattern, oxygen saturation, episodes and duration of desaturation compared to SP and PP. Episodes of desaturation <85 but >or=80 and <80% were more frequent in SP compared to PP (p = 0.0421 and p = 0.0319). Heart rate increased in SSC and PP compared to SP (154.86 bpm, SD 11.55, and 153.33 bpm, SD 15.95 vs. 150.25 bpm, SD 14.64; p = 0.0013 and p = 0.0346). Temperature level was not significantly higher during SSC and PP compared to SP except a rise between the start and the end of the 6-hour measuring cycle (37.05 degrees C, SD 0.2 vs. 37.30 degrees C, SD 0.3; p = 0.0436). CONCLUSION: We found no significant SSC-mediated changes in quality and quantity of desaturations and in body temperature compared to PP in preterm infants.

[Depression of respiration via toxic effects on the central nervous system following use of topical brimonidine in an infant with congenital glaucoma]. / Zentralnervöse Atemdepression als Komplikation der Behandlung des kongenitalen Glaukoms mit Brominidin-Augentropfen.

We report the case of a premature newborn (gestational age 33 weeks) with congenital glaucoma. After a trabeculotomy high intraocular pressure persisted, leading to adjuvant treatment with timolol and--when the infant was 3 weeks old--with brimonidine. After the first application of topical brimonidine the infant developed such severe apnoeic spells that intubation and temporary ventilation were necessary. A review of the literature reveals that when used in young infants brimonidine eye drops can potentially have toxic effects on the central nervous system (e.g. respiratory depression). The use of topical brimonidine is therefore not advised in this age group.

Effects of single and multiple doses of perfluorocarbon in comparison with continuous partial liquid ventilation on gas exchange and lung pathology in newborn surfactant-depleted pigs.

OBJECTIVE: To compare the efficacy of single, multiple, and continuous application of perfluorocarbon (PFC) FC-77 on gas exchange and lung pathology in a prolonged 24-hr study. DESIGN: Controlled animal trial. SETTING: Research laboratory in a university setting. SUBJECTS: Twenty-one newborn piglets (mean weight 1.94 kg). INTERVENTIONS: After intubation and instrumentation, the anesthetized animals were randomized in three groups: a) animals receiving one 1-hr session of partial liquid ventilation (PLV) followed by 23 hrs of conventional ventilation (CV), designated as the single PLV (S-PLV) group; b) animals receiving multiple 1-hr sessions of PLV with intermittent CV, designated as the multiple PLV (M-PLV) group; and c) animals receiving continuous PLV over 24 hrs, designated as the continuous PLV (C-PLV) group. After lung injury was induced with repeated saline lavage, specific ventilatory treatment was initiated. The oxygenation index, Pao2/Fio2 ratio, and ventilatory efficacy index were determined before and after lung injury and during the 24-hr course. After 24 hrs, the lungs were removed for histopathologic examination. MEASUREMENTS AND MAIN RESULTS: Gas exchange variables improved within 60 mins in all groups after the initiation of the specific ventilatory treatment (p < .01). The best outcome was observed in the C-PLV group, which provided a continuously stable gas exchange over the 24-hr period. S-PLV initially improved gas exchange, but after 6 hrs all variables were impaired when compared with C-PLV (p < .01). M-PLV transiently improved gas exchange variables after each PFC application; however, M-PLV was associated with a significant deterioration of all pulmonary variables during the 24-hr course. The lungs of the animals in the M-PLV group demonstrated an increased lung injury score (p < .01) and increased morphometric values (p < .05) when compared with C-PLV. CONCLUSIONS: In surfactant deficient lungs, single and multiple applications of PFC only transiently improved oxygenation. Multiple PFC fillings with intermittent gas ventilation led to a deterioration of gas exchange during the 24-hr study and severe lung damage. Continuous PLV provides the best gas exchange and the most favorable histopathologic outcome.

Association of apnea and nonacid gastroesophageal reflux in infants: Investigations with the intraluminal impedance technique.

An association of apnea and gastroesophageal reflux (GER) was proposed previously. However, pH metry as the standard diagnostic tool for GER only measures acid reflux (pH < 4). It is difficult to interpret studies in infants with a presumed association between apnea and GER based on pH metry because the buffering effect of feeding may result in predominantly nonacid GER. The aim of this study was to investigate the temporal association of apnea and GER with the pH-independent intraluminal impedance technique (IMP). Infants with recurrent regurgitation or respiratory symptoms suggestive of apnea were investigated simultaneously with IMP, pH monitoring, and polygraphy. IMP patterns, pH, oronasal flow, and chest wall movement were recorded and analyzed. In 22 infants, 364 GER episodes were recorded by IMP. One hundred and sixty five apneas were documented by visual validation of polygraph records. Forty-nine apneas (29.7%) were associated with GER; 11 (22.4%) of these showed acid reflux (pH < 4). A significant correlation between the time spent apneic and GER was found (P < 0.001). There is marked association between apnea and gastroesophageal reflux in infants. Patients potentially at risk cannot be reliably identified by pH metry. Its exclusive use is therefore not suitable for the detection of all GER-associated apneas in infants. The pH-independent intraluminal impedance technique has proven to be a sensitive diagnostic tool for this approach.

Diagnosis and stage-related treatment of disseminated intravascular coagulation in meningococcal infections.

Disseminated intravascular coagulation (DIC) is a frequent complication of meningococcal sepsis in children. Despite the availability of potent antibiotics, mortality in meningococcal disease remains high (about 10%), rising to 40% in patients presenting in severe shock and consecutive DIC. As the clinical course and the severity of manifestations of systemic meningococcal infections varies there is a need for early diagnosis of the infection and of the stage of coagulopathy in order to reduce the high mortality rate. Few and rapidly available parameters are needed to classify the wide spectrum of clinical and laboratory findings in patients with DIC. The parameters include partial thromboplastin time, prothrombin time, plasma levels of fibrinogen, antithrombin III (AT III), fibrin monomers and D-dimer concentration, fibrin degradation products and the thrombocyte count. Monitoring the course of hemostasis findings in 28 pediatric patients (age between 3 months and 8 years, mean 3.1 years) with systemic meningococcal infections we observed a change of coagulation parameters already in the first stages of the infection: A prolongation of partial thromboplastin time mean 69.1 sec (range 22-150 sec, normal 30-45 sec), a decrease of prothrombin time to 45.7% (range 13-71%, normal 70-100%) and of AT III to an average level of 70% (normal 85-125%) was found 1 to 4 (-6) hours after admission. The following deterioration of prothrombin time and partial thromboplastin time turned out to be statistically significant (p < 0.05, signed rank test). The monitoring of hemostasis parameters mentioned above made it to possible define the stage of coagulopathy and thus to start a stage related therapy. Treatment consisted of shock control by liquid substitution, compensation of metabolic acidosis, correction of clotting disorders (AT III and heparin in case of pre-DIC; AT III and fresh frozen plasma in case of advanced DIC), antibiotic treatment (beta-lactam antibiotics e.g. cefotaxime or ceftriaxone), and--when necessary--catecholamine infusions. An early assessment of the coagulation disorders in meningococcal disease can be based on few coagulation parameters. Thus an appropriate treatment can be arranged in order to prevent a fatal outcome of meningococcal sepsis and to protect against the development of a Water-house-Friderichsen-syndrome.

[Fiberoptic measurement of arterial oxygen saturation in premature and term neonates]. / Fiberoptische Messung der arteriellen Sauerstoffsättigung bei Früh- und Neugeborenen.

BACKGROUND: Non-invasive oxygen monitoring with pulse oximetry or transcutaneous monitoring has gained widespread use in neonatology. Different factors like arterial hypotension, peripheral vasoconstriction and edema adversely affect the accuracy of both methods. To ensure reliable monitoring of oxygen saturation in critically ill patients we measured oxygen saturation with a fiberoptic catheter via umbilical artery. METHODS: In ventilated premature infants (FiO2 > 0.4) a 4F-fiberoptic catheter (Oximetrix)-3, Abbott) was inserted to the descending aorta (Th 6-8). Simultaneously pulse oximetry (SaPO2) was performed with the Ohmeda Biox 3700. To compare the reliability of both methods, blood was analysed for arterial partial oxygen pressure (PaO2), fetal hemoglobin (HbF) and arterial oxygen saturation (SaO2) by complete co-oximetry (Radiometer Copenhagen OSM3) as reference. RESULTS: In 10 premature infants (median gestational age 30.5 weeks; median birth weight 1360 g) oxygen saturation was measured with the fiberoptic catheter (SaFO2) over a total period of 935 hours. In all, 137 blood samples were analysed for arterial saturation (SaO2) by co-oximetry. The mean difference between the SaO2 and SaFO2 was -1.89% (+/- 1.53); the mean difference between SaO2 and the values obtained by pulse oximetry (SaPO2) was -3.09% (+/- 2.33). The SaFO2 results correlated closely with the co-oximetry values (r = 0.97; p < 0.0001). CONCLUSION: In critically ill patients, if non-invasive oxygen monitoring fails, a fiberoptic catheter offers the possibility of continuous and reliable measurement of oxygen saturation.

Gastroesophageal reflux and respiratory phenomena in infants: status of the intraluminal impedance technique.

BACKGROUND: The coincidence of recurrent respiratory symptoms and gastroesophageal reflux (GER) is a well-known phenomenon in infants. Twenty-four-hour pH metry is the presumed gold standard of diagnostic tools for this symptom complex, but with this method, only acid (pH <4) and alkaline (pH >7) GER can be detected. Gastroesophageal reflux with an esophageal pH in the physiological range (pH 5-6.8) may represent many cases of clinically relevant GER unrecognized by pH metry. In this study the intraluminal multiple electrical impedance (IMP) procedure for complete registration of GER was compared with pH metry for its diagnostic value in the presence of respiratory symptoms. METHODS: Twenty-two infants with recurrent regurgitation or pulmonary problems were investigated simultaneously with IMP, pH metry, and polygraphy during two feeding periods. Heart rate, oxygen saturation, sleep states, and oronasal flow were recorded, among other parameters. RESULTS: Three hundred sixty-four occurrences of GER were detected by IMP; only 11.4% had a pH less than 4 and were therefore recognized by pH metry. Three hundred twelve (84.8%) occurrences were associated with breathing abnormalities, and 11.9% of these were detected by pH metry. Nineteen instances were accompanied by a decrease of oxygen saturation of more than 10% of the initial value. Only three (15.8%) of these had a pH less than 4. The remaining 16 reflux episodes were recognized by IMP only. After software-aided preselection, 165 instances of apnea were visually validated, 49 of which were accompanied by GER. Thirty-eight (77.6%) of these were exclusively recorded by IMP. CONCLUSIONS: The use of pH metry alone cannot detect most GER incidents accompanied by respiratory symptoms and therefore does not appear to be suitable for this approach. The pH-independent IMP technique promises to be a reliable tool for presumably GER-associated respiratory symptoms.

Early versus late dexamethasone treatment in preterm infants at risk for chronic lung disease: a randomized pilot study.

UNLABELLED: Abstract The purpose of this controlled, prospective pilot study was to compare the short-and long-term efficacy of early versus late treatment with dexamethasone (Dex) in preterm infants at risk for chronic lung disease (CLD). Thirty ventilated premature infants with a birth weight < or = 1250 g were randomized to receive Dex either from day 7 or from day 14. Dex was administered over 16 days tapering from 0.5 mg/kg per day to 0.1 mg/kg per day. The infants of the early treatment group could be weaned significantly earlier from the ventilator after 14 days (median; range 9-24) versus 24 days (median; range 8-44) in the late treatment group. The need for supplemental oxygen was shorter if Dex was started early - 24 days (median; range 10-57) versus 40 days (median; range 10-74). Oxygen dependency at 28 days of age was similar between the groups 6 out of 14 infants (42.9%) versus 10 out of 16 patients (62.5%). The long-term efficacy of the two Dex regimens on lung function was evaluated by body plethysmographic measurements made at the age of 3 months. Thoracic gas volume and airway resistance were measured and specific airway conductance calculated. No statistically significant differences between the groups were demonstrated. CONCLUSION: Early dexamethasone treatment led to earlier extubation in our study population, but was not associated with significant advantages regarding oxygen dependency at 28 days of life and pulmonary function test at 3 months of age.

Inhaled budesonide in ventilator-dependent preterm infants: a randomized, double-blind pilot study.

The aim of this randomized, double-blind pilot study was to evaluate the short-term efficacy of early inhalation therapy with budesonide in ventilator-dependent preterm infants. The primary outcome variable was the duration of artificial ventilation; secondary outcome variables were the need for supplemental oxygen and the release of several inflammatory mediators in the tracheobronchial aspirate fluid. The infants of the budesonide group could not be weaned earlier from the ventilator. The ventilatory parameters on day 14 of life and the need for supplemental oxygen were similar in both groups. The release of inflammatory mediators was not reduced in the budesonide group. No adverse side effects were observed in either group. In conclusion, aerosolized budesonide failed to demonstrate significant short-term pulmonary improvement in ventilator-dependent preterm infants.

[Selenium status and bronchopulmonary dysplasia in premature infants <1,500 g]. / Selen-Status und Bronchopulmonale Dysplasie bei Frühgeborenen < 1500 g.

Selenium is an essential component of the antioxidant enzyme glutathione peroxidase that protects tissues against oxidative injury by detoxifying peroxides. In preterm infants the risk for selenium deficiency is increased due to insufficient selenium uptake. Low selenium uptake and as a consequence decreased glutathione peroxidase activity may result in an elevated risk for the development of bronchopulmonary dysplasia (BPD). The aim of this prospective study was to investigate the relationship between the selenium status of preterm infants < 1500 g and the incidence of BPD. We determined the selenium plasma levels by means of atomic absorption spectrometry in 34 VLBW infants (mean birth weight 1075 +/- 249 g; mean gestational age 28.6 +/- 2.5 weeks) within the first 5 days of life and later in the age of 4 weeks. The infants received mainly parenteral nutrition and were not specifically supplied with selenium. Postnatally, the selenium plasma level was 34.2 micrograms/l (17.3/50) [median (25/75% quantil)] and dropped after 4 weeks to a median value of 16.1 micrograms/l (5.2/38.4) (p < 0.001). In the infants with BPD (n = 12) the selenium concentration within the first week of life was 45.0 micrograms/l (31.5/55.6) versus 33.2 micrograms/l (20.2/42.4) in the infants without BPD. In the age of 4 weeks of life the median selenium level was not significantly different between the infants with and without BPD - 17.2 micrograms/l (10.3/22.5) versus 14.8 micrograms/l (8.8/22.6).

The hypothalamic-pituitary-adrenal axis in preterm infants weighing < or = 1250 g: association with perinatal data and chronic lung disease.

The hypothalamic-pituitary-adrenal axis (HPA) was examined in 34 ventilated preterm infants weighing < or = 1250 g during the first week of life to evaluate the association between adrenal suppression and subsequent chronic lung disease. The second aim of the study was to detect perinatal and clinical differences between the infants with and without persistent suppression of the HPA after completion of dexamethasone treatment for chronic lung disease. To evaluate the HPA, the corticotropin-releasing hormone stimulation test was performed, and the cortisol and adrenocorticotropic hormone (ACTH) levels were measured by radioimmunoassay. No association could be found between the synthesis of cortisol and ACTH at the end of the first week of life and the development of chronic lung disease. After treatment with dexamethasone, baseline cortisol levels < 138 nmol l(-1) were found in 12 infants (46.2%), 8 of whom (30.8%) had cortisol values below 83 nmol l(-1). The perinatal data of these patients did not differ from infants without HPA suppression. However, the infants with cortisol levels < 83 nmol l(-1) after dexamethasone showed a significantly shorter need for mechanical ventilation and supplemental oxygen (p < 0.01) and a lower incidence of chronic lung disease (p < 0.05).

[Function of the hypothalamo-hypophyseal-adrenal axis to corticotropin-releasing hormone test in premature infants with bronchopulmonary dysplasia]. / Funktion der Hypothalamus-Hypophysen-Nebennierenrinden-Achse im Corticotropin-Releasing-Hormontest bei Frühgeborenen mit Bronchopulmonaler Dysplasie.

BACKGROUND: The purpose of this prospective study was to examine the hypothalamic-pituitary-adrenal axis using the corticotropin-releasing hormone stimulation test in 24 preterm infants (mean gestational age 27.4 +/- 1.4 weeks, mean birth weight 997 +/- 166 g) with bronchopulmonary dysplasia after completion of dexamethasone treatment. METHODS: The CRH stimulation test was performed before and two days after the course of dexamethasone therapy in a dosage of 1 microgram/kg body weight. Blood samples were obtained before and 30 minutes after application of CRH. The blood values for cortisol and ACTH were measured by radioimmunoassay. RESULTS: The mean basal cortisol level was significantly reduced from 338 +/- 283 nmol/l before dexamethasone treatment to 153 +/- 102 nmol/l after dexamethasone therapy. The site of HPA suppression was located to the pituitary gland as the mean basal ACTH level dropped from 9.5 +/- 5.2 pmol/l to 5.6 +/- 2.0 pmol/l after the dexamethasone course. In 9 infants there was only an insufficient increase of cortisol level after application of CRH as a possible sign of a reduced adrenal response. The patients with HPA-suppression did not differ in clinical aspects from infants without suppression of the HPA. CONCLUSION: The results demonstrate a significant suppression of the adrenal and pituitary gland in very low birth weight infants with bronchopulmonary dysplasia after dexamethasone treatment. Before stressful situations like surgery we therefore recommend an investigation of the HPA.

[Computer-assisted monitoring in the neonatal intensive care unit]. / Computerunterstützte Monitorüberwachung auf einer neonatologischen Intensivstation.

Computerized monitoring in a neonatal intensive care unit allows continuous registration and complete storage of vital parameters. The stored data can be used for detailed retrospective analysis of critically ill patients and the graphical presentation of the vital parameters may lead to an earlier recognition of clinical deterioration. This computer system which can be established in any intensive care unit demonstrates the improvement in neonatal intensive care monitoring at low financial costs.

[Primary hyperparathyroidism in the 3d pregnancy trimester]. / Primärer Hyperparathyreoidismus im dritten Schwangerschaftstrimenon.

HISTORY AND FINDINGS: A 24-year-old pregnant woman had to be hospitalized in the 33rd week of pregnancy because of premature contractions and clinical signs of pyelonephritis. She had a history of nephrolithiasis. Laboratory tests showed a total calcium of 3.6 mmol/l, hypophosphataemia of 0.59 mmol/l and an increased parathormone level of 420 ng/l. Ultrasonography demonstrated a large parathyroid adenoma, confirming the diagnosis of primary hyperparathyroidism. COURSE AND TREATMENT: Despite several recommendations of conservative treatment in the literature it was decided to perform a parathyroidectomy, which was done without complication during the 35th week of pregnancy. A healthy, mature boy was born at the beginning ot the 41st week: at no time did he show any signs of hypoparathyroidism. CONCLUSIONS: Surgical treatment of hyperparathyroidism is a reasonable and possible choice even in the 3rd trimester, because it allows regeneration of the fetal parathyroid. However, this decision must be individualized, in relation to the period of pregnancy and any progression of the disease.

[Therapy of choroid plexus carcinoma in childhood. Case report and review of the literature]. / Zur Therapie des Plexus-chorioideus-Karzinoms im Kindesalter. Fallbeispiel und Literaturübersicht.

Carcinomas of the plexus choroideus (PCC) represent the rare malignant variety of plexus choroideus papillomas and take a particularly unfavourable course. Tumors of the plexus choroideus account for about 2-4% of all primary brain tumors in children and 0.5% of those in adults. The PCC is more frequent in children than in adults; the authors found reports on 72 cases of PCC in children and on 16 cases in adults. In most cases the PCC is located in the lateral ventricles. The symptoms caused by PCC are non specific and appear as those of increased intracranial pressure (on the basis of hydrocephalus hypersecretorius and/or occlusivus). As the nature of the tumor cannot be identified by means of medical imaging, the diagnosis is usually set up histologically. Prognosis is poor for patients treated only by surgery, which in most cases has been performed as subtotal resection of the tumor. So the necessity for an oncological strategy combining surgery and 'adjuvant' therapy arises. The authors report the application of such a strategy in the case of a three-year-old boy with a PCC of the left lateral ventricle. After nearly four years of remission, the boy died of meningeosis carcinomatosa. This course underlines the malignancy of this tumor; even after years the poor prognosis can still be diminished by the spread of meningeal metastases. In a survey of the case reports published in literature the patients' data, their therapy and the outcome are demonstrated.(ABSTRACT TRUNCATED AT 250 WORDS)

[Primary hyperparathyroidism and pregnancy. Aspects of neonatal morbidity]. / Primärer Hyperparathyreoidismus und Schwangerschaft. Aspekte der Neugeborenen-Morbidität.

Primary hyperparathyroidism has to be accused to cause serious morbidity during pregnancy not only on the maternal, but also on the fetal side: the fetus is threatened by prematurity, dystrophy and an increased risk of stillbirth. Postpartually hypocalcaemia and tetany may be observed as the result of neonatal hypoparathyroidism caused by maternal and thus also fetal hypercalcaemia. We report the case of a 32-year-old pregnant woman suffering from a severe form of primary hyperparathyroidism caused by an adenoma of the parathyroidea. The tumor was removed in the 34. week of pregnancy. Six weeks later the patient delivered a healthy boy (birth weight 3450 g). A survey is given of the therapeutical procedures that should be arranged individually by interdisciplinary consulting depending on the degree of maternal disease and on the gestational age.

[Increased incidence of developmental hip dysplasia in hypertrophic newborn infants]. / Erhöhte Inzidenz von Hüftreifungsstörungen bei hypertrophen Neugeborenen.

"Lack of space" in utero is considered to be a major factor in the aetiology of the congenital dislocation of the hip. This study tries to answer the question whether hypertrophy of a newborn has to be regarded as a risk factor on the basis of the principle mentioned above. The results of postnatal clinical and sonographical examination performed on 98 large-for-gestational-age (LGA-) newborn were compared to those performed on 310 newborn children during a non selective screening program. Among the LGA-newborn pathological hip joints were found more often mainly female LGA-newborn infants were affected. It seemed that the birth weight did not correlate to the extent of the retardation of the hip joint development. It was again confirmed that the restriction to only clinical diagnostic procedures in the neonatal period is not effective in the early diagnosis of the malformation. Hypertrophy of a newborn has to be considered as a risk factor behind the development of congenital dislocation of the hip. It is recommended to examine all LGA-newborn infants post partum by clinical and most importantly also by sonographical means to recognize a retardation of hip joint development.