Intraventricular hemorrhage in the full-term neonate.

Intraventricular hemorrhage (IVH) can occur in full-term newborns with a variety of clinical pictures. We studied five full-term infants who suffered IVH in the neonatal period and survived. No apparent cause for hemorrhage could be found in four. All had normal results of neurologic examinations at birth, and four had no major antecedent perinatal or postnatal difficulties. In 19 previously described full-term infants with IVH, no perinatal problems were noted in 45% of those who survived. Although more common in premature infants, IVH can occur in full-term infants and should be suspected when there is a sudden change in the neurologic status. In subsequent examinations, three of our five infants had mild spasticity and two appeared to be normal. The grading system developed for IVH in premature infants, while indicating severity of the hemorrhage, does not predict clinical outcome in full-term infants. A more definitive statement of outcome will require a longer period of observation.

Neonatal transport nurses: an analysis of their role in the transport of newborn infants.

From September 1976 to March 1979, nurses selected from the newborn intensive care unit (NICU) assumed the transport team leadership role for 443 newborns. Each nurse had successfully completed an eight-week didactic and practical educational program in the assessment, management, stabilization, and transport of ill newborns including premature infants, those with various medical and surgical disorders, and those requiring assisted ventilation. Physician supervision and consultation was always available. The overall survival rate for these infants was 81%, a rate similar to that for newborns transported by physicians. The transport nurses consistently demonstrated the ability to effectively assess, manage, stabilize, and transport ill newborns. In addition, their utilization was alleviated a physician shortage on the NICU, has improved the response time to transport requests, and has enhanced educational opportunities for physicians and nurses.

Early-onset pneumococcal sepsis in newborn infants.

Five infants with pneumococcal sepsis presented with respiratory distress and clinical signs of infection in the first day of life. Although there was no apparent epidemiological relationship among the patients, four of the five were seen within a 12-month period. Pneumonia, prolonged rupture of fetal membranes, and prematurity were features in these patients. Three infants died, two within 12 hours of diagnosis. Streptococcus pneumoniae was isolated from the vagina of three of the mothers; in two, the serotype was identical to that recovered from their infants. Clinical features of neonatal pneumococcal sepsis are similar to those of early-onset group B streptococcal infection. Like the group B Streptococcus, S. pneumoniae acquired from the maternal vagina is a potential life-threatening pathogen in the newborn period.

Systemic candidiasis in very low-birth-weight infants (less than 1,500 grams).

Previous reports in the literature have documented that systemic infection with Candida albicans in very premature infants is frequently fatal (54%) or associated with significant morbidity in survivors (25%). Five patients with a mean birth weight of 829 g had a diagnosis of systemic candidiasis during their stay in a newborn intensive care unit. All infants survived with minimal sequelae following aggressive early treatment with amphotericin B and 5-flucytosine. A review of these five extremely premature infants and 26 previously reported patients suggests the following: (1) disseminated candidiasis is common in the absence of positive findings in blood, CSF, and/or urine cultures; (2) transient candidemia rarely resolves without therapy; (3) meningitis and osteoarthritis occur more frequently than in older patients with disseminated disease; and (4) premature infants tolerate amphotericin B and 5-flucytosine well. Infants who are found to have systemic cultures positive for candidiasis should be treated by (1) removing all factors that predispose to systemic candidiasis (eg, indwelling catheters, broad-spectrum antibiotics); (2) early initiation of systemic antifungal therapy with amphotericin B and 5-flucytosine; and (3) searching for additional foci of disease. After the disease is recognized and treatment is prompt and aggressive, outcome can be substantially improved.

Effect of antenatal administration of Betamethasone on hospital costs and survival of premature infants.

Prenatal administration of glucocorticoids has been shown to decrease in incidence and severity of respiratory distress syndrome in premature infants, but little is known regarding the immediate economic impact of this reduction in respiratory morbidity. This study retrospectively examined 342 infants born during 1978 and 1979 and hospitalized in the University of Minnesota Hospitals. Comparison of survival and the hospital charges for infants whose mothers had not received prenatal glucocorticoid therapy showed that administration of glucocorticoids has a significant effect in lowering mortality in infants with birth weights between 750 and 1,249 gm (27 to 29 weeks' gestation). Glucocorticoid therapy was also effective in decreasing morbidity as reflected by hospital charges of surviving infants with birth weights between 1,250 and 1,749 gm (30 to 32 weeks' gestation). In both steroid-treated and nontreated mothers, prolongation of gestation decreases hospital charges in a linear fashion. The noted decrease in hospital costs should not justify prenatal glucocorticoid administration but should stimulate examination of long-term effects of the drug on surviving infants.

Management of esophageal and pharyngeal perforation in the newborn infant.

Perforation of the esophagus or pharynx may occur during placement of endotracheal or nasogastric tubes in the newborn infant. Controversy exists, however, whether medical or surgical therapy is better in the management of these perforations. Nine patients who had esophageal or pharyngeal perforation in the neonatal period and were treated medically with antibiotics, nutritional support, and closed chest-tube drainage of pneumothoraces are described. All perforations healed without surgical repair. No mortality or morbidity occurred secondary to these perforations. This study, together with a review of the 73 patients described in the literature, indicate that perforations of the pharynx and esophagus can be satisfactorily managed medically. There is no apparent advantage to routine early surgical exploration. Only complications such as mediastinitis and mediastinal mass formation seem to require surgical treatment. Medical therapy with close observation for signs of sepsis and/or mediastinal changes will enable most newborn infants to avoid an operation and will identify those infants for whom surgery is definitely indicated.

Prediction of digoxin treatment failure in infants with supraventricular tachycardia: role of transesophageal pacing.

Transesophageal atrial pacing was used to initiate and terminate tachycardia in 24 infants (seven female and 17 male, aged 1 to 34 days) with ECG documentation of supraventricular tachycardia. Six infants received no chronic treatment, and chronic oral digoxin prophylaxis was administered to 18 infants in an effort to prevent recurrences of tachycardia. In these 18 infants, the effectiveness of digoxin therapy in preventing the initiation of tachycardia by transesophageal pacing was compared with its ability to prevent spontaneous recurrences of supraventricular tachycardia. While receiving chronic oral digoxin therapy, tachycardia could be reinitiated in 15/18 (83%) infants. In these infants, the cycle length of tachycardia and the atrioventricular interval were the same before and during chronic digoxin treatment. Three infants in whom tachycardia could not be initiated during chronic digoxin therapy had no spontaneous recurrences during 6 months of follow-up, whereas 10/15 (67%) infants in whom tachycardia could be reinitiated had clinically significant recurrences in spite of chronic digoxin therapy. Six infants who received no chronic drug treatment had no documented recurrences during 6 months of follow-up. This study demonstrates that digoxin was effective in preventing significant spontaneous recurrences of supraventricular tachycardia in only 8/18 (44%) infants treated with digoxin. The ability to initiate supraventricular tachycardia with transesophageal pacing may be useful in determining which digoxin-treated infants are at risk for recurrence. Finally, not all infants with supraventricular tachycardia require chronic prophylaxis; six of the untreated infants had no documented recurrences.

Reduced thrombus formation with silicone elastomere (silastic) umbilical artery catheters.

This report describes clinical experience with a radiopaque silicone elastomere (Silastic) umbilical artery catheter. Twenty infants, ten with polyvinyl chloride (PVC) umbilical artery catheters and ten with Silastic umbilical artery catheters, all positioned at the aortic bifurcation, had aortograms performed at the time of catheter removal. Catheter-associated thrombus formation was observed in nine of the ten infants (90%) with PVC umbilical artery catheters and in one of the ten infants(10%) with Silastic catheters. The incidence of lower extremity vasospasm associated with the two catheters was not significantly different. Aortic pressure tracing recorded through Silastic catheters were accurate, but slightly damped. Autopsies were performed on five additional infants who died with indwelling Silastic umbilical artery catheters. None of the catheters, nor their surrounding tissues, showed evidence of thrombus formation on either gross or microscopic examination. It is our experience that radiopaque silicone elastomere tubing can be used as an umbilical artery catheter and appears to have the advantage of being less thrombogenic than the standard PVC tubing currently in general use.

Transesophageal study of infant supraventricular tachycardia: electrophysiologic characteristics.

Programmed electrical stimulation of the heart to initiate and terminate tachycardia and analysis of the temporal relation between ventricular and atrial activation during tachycardia have been useful in the evaluation of supraventricular tachycardia (SVT). Such techniques have rarely been applied to evaluate infants with SVT. We used a silicone rubber-coated bipolar electrode catheter (15 or 22 mm interelectrode spacing), positioned in the esophagus, for electrical stimulation of the heart and recording of electrograms for the evaluation of 14 infants aged 1 to 84 days with SVT. Three infants had electrocardiographic features of Wolff-Parkinson-White syndrome, and no infant had other manifestations of congenital heart disease. Tachycardia cycle lengths ranged from 180 to 295 ms and ventriculoatrial intervals recorded from the esophagus were 80 to 220 ms. In 12 infants, transesophageal atrial stimulation was used to terminate and initiate SVT using stimuli of 9.9 ms and 10 to 20 mA. Initiation and termination of SVT by electrical stimulation suggest that SVT in infants is due to reentry, and the presence of ventriculoatrial intervals greater than 70 ms further suggests that accessory atrioventricular connections (usually concealed) constitute a portion of the reentry circuit.

Nissen fundoplication for gastroesophageal reflux in infants.

Some degree of gastroesophageal reflux is very common in infants and tends to reverse with time. Therefore, the indications for an antireflux operation are not well defined. Furthermore, the complication rate and the ability of the fundoplication to grow remain to be determined. To answer these questions, we reviewed the records of patients 6 months of age or younger who underwent a Nissen fundoplication with gastrostomy tube placement between 1979 and 1985. There were 45 patients (25 boys and 20 girls) with birth weights of 0.65 to 4.3 kg. The consequences of gastroesophageal reflux were more varied than in older children. Severe respiratory problems were common, including recurrent aspiration or bronchopulmonary dysplasia in 60% and frequent apneic and bradycardiac spells in 17%. Failure to gain weight was present in 20% and intractable vomiting in 2.0%. As expected, 78% of these patients had congenital anomalies or acquired problems which, in many cases, were important to the prognosis. The diagnosis was confirmed by barium swallow in all but one patient in whom gross reflux during feedings was present. Initially, medical management was tried for 3 to 4 weeks. In one patient, however, the severity of the respiratory problems precluded trial beyond 12 days. The recommendation for operation was based only on the severity of symptoms attributed to gastroesophageal reflux. All patients underwent Nissen fundoplication with gastrostomy tube placement at 2 weeks to 6 months of age and weighing 1.02 to 6.95 kg. The only surgical complication was one gastrostomy leak. Prematurity or preexisting anomalies led to a 20% incidence of late unrelated deaths between 2 weeks and 23 months postoperatively. Improvement in symptoms occurred in our survivors with follow-up of 5 to 72 months. We conclude: Significant gastroesophageal reflux in infancy most frequently produces respiratory problems that can be life threatening. Nissen fundoplication can be a safe and effective procedure in infants 6 months of age or younger. Fundoplication appears to have good growth potential, and no late complications or feeding problems have occurred. Consequently, surgical correction can be recommended for infants not responding to conservative medical therapy.

Correction of esophageal atresia with distal tracheoesophageal fistula.

Correction of the full spectrum of esophageal atresia with tracheoesophageal fistula (TEF) remains controversial. Circular myotomy and other lengthening procedures have shown promise to reduce tension when a relatively wide gap exists between esophageal segments; nevertheless a relatively high complication rate persists. We believe anastomotic tension is commonly found with repair of this anomaly. Therefore, the construction of the anastomosis will be a primary determinant of success. Twenty-four infants with TEF were admitted, 12 (50%) weighing 2.5 kg, nine (37%) 1.8 to 2.5 kg, and three (13%) 1.8 kg. All underwent gastrostomy and end-to-end single-layer anastomosis. Gaps of up to 4.5 cm were encountered, and in one case a cervical incision was necessary for mobilization of the upper pouch. For eight patients (33%) the gap was at least 2.5 cm and significant anastomotic tension was generated. For the series, there were no anastomotic leaks (all confirmed by barium swallow), reoperations, or surgical complications (there were two late, unrelated deaths). Prophylactic dilation was routinely performed 6 weeks and 3 months postoperatively. Subsequently, seven of the 24 (29%) required additional (one to five) dilatations but are now asymptomatic at least 2 years later. Follow-up for the entire series is 5 months to 5 years. Three infants (13%) required fundoplication for reflux without stricture and two infants (8%) an aortopexy. For successful esophageal anastomosis we consider the following technical points important: (1) no-touch technique to minimize tissue damage, (2) generous (5 to 7 mm) full-thickness suture depth, (3) fine (6/0) monofilament suture to reduce tissue reactivity, and (4) in cases of significant tension, the sutures are preplaced and used to provide traction to eliminate tension during tying. Tension is often unavoidable in TEF, yet a carefully constructed anastomosis will withstand this stress. This approach provides results at least as satisfactory as the reported experience with a variety of techniques.

The changing spectrum of cystic pulmonary lesions requiring surgical resection in infants.

Congenital labor emphysema and cystic adenomatoid malformation have been the most common surgically treatable cystic lesions of the lung. With the successful treatment of newborn respiratory distress syndrome, an increased frequency of an acquired form of cystic disease, interstitial pulmonary emphysema, has been observed. Some degree of interstitial pulmonary emphysema is relatively common, and during the years 1980 to 1983 this disease was diagnosed in 372 infants. Seven of these infants, all premature, underwent resection of relatively localized areas of persistent cystic interstitial pulmonary emphysema. Lobectomy or wedge resection was performed in five patients because of their inability to be weaned from the ventilator. A sixth patient with this disease underwent lobectomy for recurrent pneumothoraces. A seventh patient underwent lobectomy because the cystic interstitial pulmonary emphysema produced atelectasis and recurrent infections. All seven patients were extubated by the fourth postoperative day, have been discharged, and are showing respiratory improvement. Within the same period, four infants had congenital lobar emphysema and two had congenital cystic adenomatoid malformation. They were gestational age 36 weeks or older and, although respiratory distress was present to some degree in all six, only one was ventilator dependent at operation. All underwent lobectomy and one infant had a left upper lobe resection and right middle lobectomy on separate occasions for bilateral congenital cystic adenomatoid malformation. All patients with congenital labor emphysema and congenital cystic adenomatoid malformation have been discharged and are doing well. Our results suggest the following conclusions: Persistent interstitial pulmonary emphysema is now the most common indication for pulmonary resection in the newborn period. The anatomic distribution of resected interstitial pulmonary emphysema is similar to that of congenital lobar emphysema. Although only a small fraction (less than 2%) of patients with interstitial pulmonary emphysema require operation, the development of relatively large discrete cystic areas that (1) significantly decrease effective lung volume and produce respirator dependence, (2) produce atelectasis and recurrent infections, or (3) lead to pneumothoraces may make pulmonary resection beneficial. Finally, despite the presence of generalized lung disease in patients with interstitial pulmonary emphysema, these patients can be expected to improve significantly after resection, and the long-term outcome is generally good.

Correlation of clinical and pathologic findings in early onset neonatal group B streptococcal infection with disease severity and prediction of outcome.

This study analyzed the clinical characteristics of 69 neonates who were admitted to the University of Minnesota Hospital between January, 1972, and June, 1984, with early onset Group B streptococcal infection (EOGBS) and determined those features associated with fatal infection. The incidence of EOGBS was 1.6 cases/1000 live births among 7960 inborn infants; the mortality rate for inborn and outborn infants was 28%. Multivariate analysis identified five features adequately predicting fatal outcome: birth weight less than 2500 g, absolute neutrophil count less than 1500 cells/mm3, hypotension, apnea and a pleural effusion on the initial chest radiographs. With these five variables and an initial blood pH less than 7.25, a clinical score was constructed that correctly predicted outcome in 93% of patients in this study (87% sensitivity, 95% specificity). Autopsy findings in 16 of 19 infants with fatal EOGBS suggested that surfactant deficiency respiratory distress syndrome was common in preterm infants with EOGBS and contributed to their higher mortality compared with term infants.

The failure of neonates to form red blood cell alloantibodies in response to multiple transfusions.

Red blood cell alloantibody production was studied in 90 neonates who received a mean of 14.1 transfusions (range 2-35) from an average of 8.9 donors during the first three months after birth. Standard antibody detection procedures were done with the use of a selected red blood cell panel. No unexpected alloantibodies were detected. These findings suggest, at a 99% confidence level, that neonates do not make red blood cell alloantibodies in response to transfusion, indicating that repeated compatibility testing is probably unnecessary. Thus, following initial antibody screening and compatibility tests, further compatibility testing can be eliminated.

Intrauterine aspiration of a large fetal ovarian cyst.

Most large series of neonatal ovarian cysts are limited to those diagnosed in the newborn period. Eight cases of fetal ovarian cysts diagnosed prenatally by ultrasound have been reported, only one of which was aspirated in utero. Reported is the youngest fetus to undergo in utero aspiration of an ovarian cyst to reduce the risk of secondary pulmonary hypoplasia.

Neonatal pneumopericardium: a surgical emergency.

Pneumopericardium, a complication of ventilatory management of neonatal respiratory distress syndrome, may result in cardiac tamponade. Pneumopericardium occurred in 47 premature infants (mean birth weight, 1,894 gm) at the University of Minnesota Hospital between July, 1972, and January, 1981. At the onset of pneumopericardium, 44 of 46 intubated patients were on positive end-expiratory pressure (PEEP) and 1 patient was ventilated using a mask. Five infants were asymptomatic, while 42 were seen with sudden hypotension, bradycardia, and hypoxia an average of 57 hours (range, 1 to 312 hours) after the commencement of ventilatory support. Pneumothorax (38 instances), pneumomediastinum (21), pulmonary interstitial emphysema (29), pneumoperitoneum (6), or a combination of these conditions was noted prior to or simultaneously with pneumopericardium in 46 infants. Pneumopericardium was not treated in 14 patients, 10 of whom were symptomatic and 4 asymptomatic; there were 5 deaths in this group. The group of 33 infants treated for this complication underwent either pericardial aspiration (2 patients), aspiration followed by pericardial tube placement (12 patients), or pericardial tube placement alone (19 patients). All 33 patients who underwent treatment had resolution of symptoms, but pneumopericardium recurred in 13 with 5 deaths. Causes of recurrence were tube or aspiration failure in 10 infants and tube removal prior to cessation of PEEP in the other 3. There were five complications related to tube placement, resulting in 2 deaths due to myocardial laceration following percutaneous insertion. Of 35 neonates surviving pneumopericardium, 12 were discharged from the hospital and 23 died of complications of respiratory distress syndrome.(ABSTRACT TRUNCATED AT 250 WORDS)

Apomorphine: clinical studies on erectile impotence and yawning.

1. The erectile response to the short-acting dopamine (DA) receptor agonist, apomorphine (Apo) HCl (0.25, 0.5, 0.75 and 1.0 mg sc), and placebo was evaluated in 28 impotent patients and penile circumference monitored using a mercury strain gauge and strip chart recording. 2. A full erection (increment in penile circumference greater than 2 cm and lasting at least one minute) occurred in 17 patients with Apo; no erection developed after placebo. An erection occurred in 6/8 patients with impaired glucose tolerance, 2/6 patients with diabetes mellitus and in both patients on lithium. 3. Nine patients who responded to Apo were treated in an open trial with bromocriptine; 6 reported improvement in potency. 4. Impairment in DA function may play a role in idiopathic impotence and in impotence associated with impaired glucose tolerance and diabetes mellitus. 5. An erectile response to Apo may predict therapeutic response to bromocriptine or other long acting dopaminergic agents. 6. Lithium, which inhibits DA-sensitive adenylate cyclase, does not prevent Apo-induced erections. This provides further support indicating that Apo induces erections by an effect on D2 receptors. 7. The yawning response to placebo and four doses of Apo HC1 (3.5, 5.0, 7.0, and 10.5 ug/kg sc) was evaluated in five normal men using a polygraphic technique. The yawning response was also assessed in normal young (less than 30 yrs; N = 16) and elderly (greater than 60 yrs; N = 12) volunteers. 8. Under experimental conditions of study, placebo induced spontaneous yawning. This was antagonized by 3.5 and 5.0 ug/kg Apo HC1 but increased by 7.0 ug/kg Apo HC1. These observations are compatible with the view that Apo HC1 in doses of 3.5-5.0 ug/kg stimulates presynaptic DA receptors whereas 7.0 ug/kg stimulates postsynaptic DA receptors. 9. Spontaneous and Apo-induced yawning were significantly decreased in the elderly which suggests that D2 receptor function declines with normal aging.

Bombesin-, calcitonin-, and serotonin-immunoreactive pulmonary neuroendocrine cells in acute and chronic neonatal lung disease.

Bombesin-, calcitonin-, and serotonin-immunoreactive pulmonary neuroendocrine cells (PNEC) were quantitated in the lungs of infants dying of hyaline membrane disease (HMD) and bronchopulmonary dysplasia (BPD). When compared with the lungs of age-matched control infants dying of noncardiopulmonary causes, infants who had HMD demonstrated a decrease in the numbers of bombesin-, calcitonin-, and serotonin-immunoreactive PNECs, while infants who had BPD demonstrated an increase. This difference was most pronounced at 2 months of age, when infants with BPD had a threefold increase in bombesin-, a tenfold increase in calcitonin-, and a 34-fold increase in serotonin-immunoreactive cells. In both control infants and infants who had acute and chronic lung disease, a consistent relationship was found between numbers of the three cell types: bombesin greater than calcitonin greater than serotonin. Radioimmunoassay of lung tissue from infants dying of HMD and BPD confirmed low levels of bombesin immunoreactivity in HMD and increased levels in BPD. Circulating plasma bombesin levels in neonates, as measured by radioimmunoassay, were significantly higher than levels found in adults. Though these findings are intriguing, the documentation of a causal relationship between observed alterations in PNEC and the vascular and gas exchange abnormalities known to be associated with HMD and BPD must await further studies.

Drug use in the newborn. Effects on the kidney.

In the neonate, there are a number of age-related differences in drug disposition (bioavailability, distribution, metabolism, and excretion), and these are directly related to the degree of prematurity. This article discusses the use of drugs that are commonly administered to the neonatal patient, with special emphasis given to renal considerations. These drugs include diuretics, theophylline, converting enzyme inhibitors, calcium channel blockers, indomethacin, and dopamine.

Factors affecting attachment between infants and mothers separated at birth.

A sample of 24 healthy Neonatal Intensive Care Unit (NICU) survivors separated from their mothers for a period of more than 10 days after birth were studied at approximately 1 year postconceptional age to assess mother-infant attachment. The 24 infants were classified into secure-attached (N = 17) and insecure-attached (N = 7) groups according to Ainsworth categories. No differences were found between the groups in birth weight, gestation, length of NICU hospitalization, Bayley developmental scores, and 1-year physical measurements. Secure-attached infants, however, tended to be from younger, working mothers and had more day-care experiences. The data do not support the hypothesis that prolonged neonatal separation has detrimental effects on later mother-child interaction.