Percutaneous insertion of silastic central venous catheters in newborn infants.

Percutaneous insertion of a very narrow (0.635-nm outside diameter) Silastic catheter for delivery of central hyperalimentation was performed on infants in the Newborn Intensive Care Center. Insertion of the catheter into the external jugular or basilic vein was successful in 15/17 (88%) infants, including four weighing less than 1,000 gm. Catheters remained in place for 446 patient-days (mean 24.8 +/- 15.9 days). Culture-proven infection, thrombophlebitis, or caval obstruction did not occur. Percutaneously placed central Silastic catheters proved to be a safe and effective alternative to surgically placed catheters.

Increased lead burden in children of battery workers: asymptomatic exposure resulting from contaminated work clothing.

Lead transmitted into the home via contaminated parental work clothing was the probable source of excessive lead exposure among 69% of 58 children whose mothers worked in a battery factory in Raleigh, North Carolina. Blood lead levels were highest in children less than 3 years old, and declined with age. All children were asymptomatic, and all had normal findings on physical examinations. Dust samples from the homes of children with the greatest lead burden demonstrated gross contamination of the home environment. Although maternal employment was short, young children spent a significant portion of their lives exposed to lead. Certain parental occupations can sufject children to considerable risk from lead exposure.

Hazard of lead exposure in the home from recycled automobile storage batteries.

Two families from rural areas of North Carolina had excessive lead exposure which resulted from either recycling exhausted automobile storage batteries in the home or burning the discarded battery casings for home heating. One child developed encephalopathy resulting in permanent brain damage. Decontamination efforts reduced the quantity of lead in the home environment by greater than 50%. Rural children, previously considered to be at low risk, may in fact receive profound exposures which may go unrecognized until encephalopathy occurs. Occupational histories should be obtained from parents in order to detect children at risk from environmental toxins brought into the home on workmen's bodies and clothing.

Commitment to change: a strategy for promoting educational effectiveness.

BACKGROUND: Short lecture-based courses are the most common format used in continuing medical education (CME) activities, yet they are relatively ineffective for inducing behavioral changes. This study investigates the effectiveness of the commitment to change strategy for identifying behavioral changes stimulated by such a short course. METHODS: Attendees at an annual 3-day lecture-based course voluntarily committed to instituting up to four changes in their practice. Those who made commitments were surveyed 1 month following the conference. RESULTS: Fifty-four percent of the intended changes had already been accomplished. There was no relationship between the audience's post-lecture evaluation scores for achieving the learning objectives compared to the number of changes committed to by the attendees. IMPLICATIONS: An unanticipated finding was the differential participation between those professions that have more autonomy (physicians and advanced practice nurses) versus those professions with less (nurses and physician's assistants). Insufficient elapsed time was the nearly universal limitation for initiating change. Encouraging participants to make a commitment to change holds a great deal of potential for both stimulating and documenting behavioral outcomes resulting from CME activities.

Insertion of a small central venous catheter in neonates and young infants.

Total parenteral nutrition (TPN) administered through a central venous catheter in low-birthweight neonates and infants has been complicated by mechanical catheter malfunctions and catheter-associated infections. A retrospective survey of catheter complications 66 infants with 90 pediatric Broviac (1.3 mm o.d.) and large-diameter (French size 3, 4, and 5) Silastic catheters revealed 17 mechanical malfunctions (27%) and 16 cases (26%) of catheter infections. The current study presents our experience using 58 small-diameter (0.635 mm o.d.) Silastic catheters for TPN in 53 neonates and infants. There were 13 episodes (22%) of mechanical problems such as accidental dislodgement, occlusion of the catheter, and perforation of the tubing. Only four cases (7%) of catheter-associated sepsis occurred, a significant reduction (p = 0.008) in this serious problem compared to the previous large catheter study. We have compared clinical features of both large- and small-diameter catheters and suggest specific guidelines for their use. The small-diameter Silastic catheter is safe, easily inserted, and effective in the critically ill, low-birthweight neonate and in young infants weighing less than 6 kg. The pediatric Broviac catheter is recommended for administration of long-term or home TPN to infants and children greater than 6 kg. These catheters are useful for multiple purposes such as blood drawing, chemotherapy, and nutritional support while the small catheter is not as versatile.

A microprocessor-based instrument to measure pulmonary functions in critically-ill newborn infants.

Despite advances in the medical care of critically-ill newborn infants, chronic complications due to intense ventilatory support are common. Selection of ventilator settings is empirical, since measurement of pulmonary functions in newborn infants is not commonly performed. A microprocessor-based instrument was constructed to measure pulmonary function in critically-ill newborn infants with respiratory failure. Data collected fail to demonstrate any beneficial effect upon pulmonary mechanics with increasing amounts of continuous distending airway pressure, and in fact demonstrate an adverse effect upon the lung ventilation. These results demonstrate the need to measure pulmonary function to develop procedures to select optimum ventilator settings. A microprocessor-based system is suitable for such an application, and could be incorporated into future infant respiratory support equipment.

Contributions of the caregiving environment to increased lead burden of children.

Two groups of children, 12 to 30 months (n = 14) and 31 to 78 months of age (n = 12), showing increased lead burden were compared to a sample of children matched for age, sex, and socioeconomic status but showing no evidence of increased lead burden. All children were screened at a local county health department because of suspected lead exposure or as part of the Early and Periodic Screening, Diagnosis, and Treatment Program. The quality of the caregiving environment was assessed using the HOME Inventory. A measure of maternal intelligence was also obtained. For the younger children, significant deficits in maternal IQ and quality of the caregiving environment were associated with increased lead burden. In particular, the subscales of the HOME Inventory dealing with emotional and verbal responsivity of the mother and maternal involvement with the child were significantly lower for children with increased lead burden. For the older children there was no significant association between lead burden and home environment or maternal IQ. The results suggest that intellectual deficits previously attributed to lead toxicity may be related to compromised home environment.

Neonatal and infantile hypoglycemia due to insulin excess: new aspects of diagnosis and surgical management.

Persistent hypoglycemia in the neonate and young infant usually results from inappropriate, excessive secretion of insulin, or a deficiency of one of the hepatic gluco-regulatory enzymes. Hypoglycemia due to hyperinsulinism, whether associated with nesidioblastosis, islet cell hyperplasia, adenoma or normal islets, may have devastating consequences in this age group and demands recognition and effective treatment. Medical management consisting primarily of frequent feeding, the intravenous infusion of glucose and the administration of glucagon, glucocorticoids, epinephrine, and diazoxide is often ineffective and may be punctuated by repeated episodes of hypoglycemia, convulsions, and central nervous system damage. Although subtotal-total pancreatectomy is effective in restoring blood sugar to normal, almost half of the reported patients are mentally retarded. This may be due in part to unwarranted delays in performing pancreatectomy. Experience with 6 patients undergoing subtotal--total pancreatectomy for intractable hypoglycemia supports the contention that this procedure is effective. A euglycemic state was restored in all 6 patients and there was no evidence of residual central nervous system damage. The spleen should be preserved in view of its importance in maintaining normal immunodefense mechanisms.