New fontanometer for continuous estimation of intracranial pressure in the newborn

Intracranial pressure was estimated by a new pneumatic applanation fontanometer in babies in intensive care. A close correlation with cerebrospinal fluid pressure was found on 35 separate occasions. In 12 control babies the mean (SD) fontanelle pressure was 5.2 (2.2) cm H2O, in eight with a hypoxic-ischaemic encephalopathy it was 12.6 (4.3) cm H2O, and in nine with post-haemorrhagic hydrocephalus it was 10.8 (4.3) cm H2O. In four babies monitored continuously over seven days the correlation remained good. The fontanometer enables pressure to be monitored accurately, continuously, and non-invasively in neonates at risk of raised intracranial pressure.

Nonnutritive sucking in the sick infant

The role of nonnutritive sucking (NNS) in the care of the sick infant is discussed. Several benefits may be derived from NNS: 1) in behavioral and physiologic terms; 2) the maturation of the sucking reflex, the resulting efficiency in feeding, and early hospital discharge; and 3) the change in the perceptions of the caretakers in their alertness and responsiveness to the infants' needs.

Splenic function: physiology and splenic hypofunction

A wide variety of disorders can result in diminished splenic function. The pathophysiology appears to be clearly defined in some instances, such as congenital asplenia and disorders of splenic vascular obstruction or congestion. In others, such as the autoimmune and GI disorders, the mechanism remains poorly defined. Further research is needed. The hyposplenia which occurs in many of these disorders has been associated with an increased risk of life-threatening, overwhelming bacterial sepsis. In other instances, this complication has not been reported. This certainly should not be interpreted to mean that it cannot occur. The risk of septicemia in hyposplenic disorders is rarely above 10 to 15%. In disorders with minimal inhibition of splenic function, the incidence of sepsis would presumably be less than the 1.5% incidence following surgical splenectomy for trauma. Considering these data, a very large number of patients would have to become asplenic before it would be likely that one would develop sepsis. Furthermore, the lack of awareness of the possibility of hyposplenia-related sepsis in many of these disorders may cause such occurrences to go unrecognized. Finally, since the risk of sepsis is probably less in hyposplenic adults as compared to children, studies on adults may underestimate the incidence of this complication in children. Many of the disorders reported to cause hyposplenia in adults have not been noted to do so in children. In instances such as celiac disease, it may take many years for the complication to manifest so that it would be unlikely for a child to manifest hyposplenia during childhood. However, in other instances, not enough children have been studied to be confident that the hyposplenia and its associated risk of sepsis are not complications that occur in children. Hyposplenia-related bacterial septicemia is a catastrophic complication. If a patient develops a disorder that is potentially associated with hyposplenia, the patient should be observed for signs of asplenia in the peripheral blood. If the technique is available, quantitation of red cell pits should be performed. If not, other studies of splenic function such as radionuclide scans should be considered, depending on the incidence of hyposplenia in that particular disorder. If evidence of asplenia develops, pneumococcal vaccine should be administered, penicillin prophylaxis should be considered, significant febrile episodes should be managed aggressively, and probably most importantly, the patient and family should be carefully educated about this complication. Most deaths from hyposplenia-related septicemia are preventable.

Lung function in infancy and childhood following neonatal intensive care

Pulmonary function studies were performed in 11 neonatal intensive care survivors both during infancy and later in childhood. Lung function was compared with the respiratory support given in the neonatal period. The mean +/- SE thoracic gas volume was 96 +/- 4% predicted in infancy and rose to 122 +/- 8% predicted during childhood (P less than 0.005). The specific airway conductance (SGaw) in infancy was 57 +/- 7% predicted and rose to 90 +/- 8% predicted in childhood (P less than 0.0025). Abnormalities in SGaw were found only in ventilated infants, and there was a negative logarithmic correlation between the treatment score in the neonatal period and the SGaw in both infancy and childhood. The data indicate a long-term improvement in airway conductance of moderately affected infants with the development of mild hyperinflation in childhood possibly resulting from residual small airway abnormalities despite a symptomless clinical course. The residual abnormalities in prematurely born infants were in proportion to the intensity of treatment required in the neonatal period.

Quantification of cerebral oxygenation and haemodynamics in sick newborn infants by near infrared spectrophotometry

New apparatus was made whereby indices of cerebral oxygenation and haemodynamics in sick newborn infants could be quantified by near infrared (NIR) spectrophotometry and displayed instantaneously at the cotside. The indices included oxygenated haemoglobin, reduced haemoglobin, oxidised cytochrome aa3, and total haemoglobin concentration: cerebral blood volume, mixed cerebral venous saturation, and changes in cerebral blood flow were then derived. Striking changes were observed in response to alterations in arterial oxygen saturation and carbon dioxide tension and to tilting of the infant. Abnormal responses were detected in cerebral oedema following birth asphyxia, patent ductus arteriosus, and cystic encephalomalacia. NIR spectrophotometry provides valuable quantitative data at the cotside for the management of sick infants and for exploring the pathophysiology of damage to the brain.

Method of pulmonary and membrane lung gas exchange measurement during extracorporeal membrane oxygenation

A method for measuring simultaneous MemL and NatL gas exchange during neonatal ECMO has been described. Closed-circuit spirometry techniques were used for both measurements. This technique demonstrated minimal pulmonary gas exchange at low airway pressures prior to pulmonary recovery and measured the gas exchange of metabolism in these critically ill neonates.

The pharmacology of neonatal resuscitation and cardiopulmonary intensive care. Part II--Extended intensive care

An optimal outcome for a distressed newborn infant can be achieved only if immediate resuscitation is followed by appropriate cardiopulmonary intensive care. In the preceding article in this series, we provided recommendations for drug therapy during the initial resuscitation. When an infant is stable enough for transfer to an intensive care nursery, extended cardiopulmonary intensive care should be initiated. If the infant remains distressed, this may require drug therapy to improve cardiac output, either by enhancing cardiac performance (dopamine, dobutamine or epinephrine) or by reducing afterload (nitroprusside). Drugs that alter the distribution of the circulation may be required for infants with persistent hypoxemia due to pulmonary hypertension or congenital heart disease (tolazoline, nitroprusside, prostaglandin E(1)), or with pulmonary congestion due to persistent patency of the ductus arteriosus (indomethacin). Infants with pulmonary disease may benefit from administration of agents that alter pulmonary function (furosemide, nitroprusside or neuromuscular blockers). Finally, treatment of the underlying disorder, with antibiotics or naloxone, for example, must not be neglected.

Inadequate humidification of respiratory gases during mechanical ventilation of the newborn

Proximal airway humidity was measured during mechanical ventilation in 14 infants using an electronic hygrometer. Values below recommended minimum humidity of adult inspired gas were recorded on 251 of 396 occasions. Inadequate humidification, largely due to inadequate proximal airway temperature, is commoner than recognised in infants receiving mechanical ventilation.

Factors influencing neonatal morbidity in diabetic pregnancy

The influence on neonatal morbidity of factors such as maternal duration of diabetes, third trimester blood glucose control, gestational age at delivery, mode of delivery, and hypertension in pregnancy was analyzed in 92 consecutive diabetic pregnancies (White B35, C22, D26, F9). In a subgroup of 52 diabetic pregnancies the analysis was extended to the influence of hemoglobin A1c at the start and end of pregnancy, blood glucose control during delivery, and fetal insulin secretion at birth. The infants were divided into 3 groups according to the degree of neonatal morbidity: either no (n = 37), minor (n = 27), or severe morbidity (n = 28). There were no significant differences between the groups with no and minor morbidity. Compared to the no-morbidity group, the group with severe morbidity had significantly longer duration of maternal diabetes (p less than 0.05), shorter gestational age at delivery (p less than 0.025), higher frequency of cesarean section (p less than 0.05), and higher frequency of toxicosis (p less than 0.01). The 3 groups did not differ significantly with regard to maternal blood glucose control during pregnancy and delivery. Discriminant analysis revealed that the most significant (p less than 0.001) influence on severe morbidity came from gestational age at delivery. After correction for this factor, there were no other factors with a significant influence on severe morbidity. Within the actual range (mean values 3.9-8.5 mmol/l), blood glucose control during the third trimester had no significant influence on morbidity.

Cassette electroencephalography in the evaluation of neonatal seizures

Three-channel cassette electroencephalographic (EEG) recording for up to 24 hours was obtained from 37 neonates with clinically diagnosed or suspected seizures but no seizure activity on routine EEG. EEG seizures were recorded in seven patients, five of whom had experienced clinical seizures in the 24 hours prior to cassette EEG recording. EEG seizures were detected in only one of nine neonates with recurring clinical episodes believed unlikely to be seizures and in only one of 18 without recent clinical events. Cassette EEG can enhance the detection and differentiation of seizures in neonates with persistent clinical episodes but is of low yield otherwise.

Response to ACTH in the newborn

Adrenocortical function was studied in 52 newborn infants who had been divided into three groups: preterm well, preterm ill, and term ill. Basal plasma 17-hydroxyprogesterone concentrations were significantly increased in both groups of preterm infants. There was no significant difference in basal plasma cortisol concentrations, although they were highest in preterm ill infants. All infants responded to adrenocorticotrophic hormone (ACTH) stimulation (36 micrograms/kg intramuscularly) with a two to three fold increase in the concentration of both steroids. The peak plasma 17-hydroxyprogesterone response was significantly higher in preterm ill infants. A subgroup of five infants, who were highly stressed but had undetectable basal plasma cortisol concentrations, also showed an appropriate response to ACTH. The results provide useful reference data to assess adrenal function in the infant of a mother given glucocorticoids during pregnancy. There is also a change from the pattern of fetal adrenal steroidogenesis soon after birth, which may be affected by exogenous ACTH stimulation. Roughly 10% of stressed newborns failed to synthesise cortisol basally; temporary glucocorticoid replacement for such infants may be appropriate.

Intravenous paraldehyde for seizure control in newborn infants

We studied 14 newborn infants with seizures after birth asphyxia or other causes. Paraldehyde was given as a 200 mg/kg IV bolus followed by an infusion of 16 mg/kg/h (10 cases), or as a 400 mg/kg bolus (4 cases). Serum concentrations of paraldehyde were higher in periods of adequate seizure control than in periods of little or no response. Paraldehyde serum concentrations above 10 mg/dl were associated with anticonvulsant effects and were achieved in most neonates with a 2-hour infusion of 200 mg/kg/h. If there is no effect, serum concentrations are probably below 10 mg/dl and an additional 200 mg/kg can be given safely over 1 hour.

Peripheral nerve conduction studies in passively addicted neonates

Neurologic signs dominate the manifestations of the neonatal abstinence syndrome (NAS). To help delineate this dysfunction, peripheral nerve conduction studies (NCS) were made in 25 neonates born to methadone-maintained mothers; 12 of the mothers abused other controlled substances concomitantly. Median and common peroneal motor nerve conduction velocities (NCV) in these infants were normal, both at three to seven days and three to four weeks of age, and were unaffected by maternal drug intake pattern, severity of neonatal abstinence symptoms, treatment with either camphorated tincture of opium or phenobarbital, intrauterine growth retardation, or abstinence-associated seizurer. Electromyographic findings were normal in 21/23 infants; two others showed minimal partial denervation, characterized by fibrillations and positive sharp waves. NCV in the NAS may enhance gestational age assessment and therefore increase validity of neurobehavioral follow-up. Our studies continue to point to a central rather than a peripheral motor dysfunction exhibited by passively addicted infants at birth, which may persist on two-to-five-year follow-up.

Neonatal assessment: an overview

The purpose of this paper is to provide an overview of assessment techniques used by physical therapists in the assessment of the neonate. An additional purpose is to provide a review of prenatal and postnatal development in the areas of muscle tone, range of motion, somatosensory skills, and reflex development. The role of the physical therapist on the neonatal team is discussed relating to the types of assessments physical therapists might use in evaluating the neonate. General considerations for assessment are provided, and specific areas including physical examination, behavioral assessment, evaluation of muscle tone, reflex assessment, oral motor evaluation, and sensory systems assessment are discussed. Physical therapy for the neonate has been considered as a specialty area of pediatrics. Physical therapists, however, are being asked to function in neonatal units in hospitals as a part of their practice in the general hospital setting. This article provides information for the inexperienced clinician who is interested in working with the neonate and for the experienced clinician.

Birth stress and self-reported sleep difficulty

Difficulty in falling asleep and frequency of night wakenings were assessed in 1,272 college-aged individuals for whom birth histories (based on retrospective maternal reports) were available. A history of birth complications was associated with reports of sleep difficulties as an infant. Birth stressors, such as breech birth, prolonged labor, low birth weight, and multiple births, were predictive of disrupted sleep patterns in the young adult.

Cerebral cortical function in infants at risk for sudden infant death syndrome

Cerebral cortical function was prospectively examined by electroencephalography (EEG) in 3 subgroups of 257 infants at risk for sudden infant death syndrome (SIDS). Group 1 consisted of apparently healthy infants with near-miss SIDS episodes; Group 2 consisted of siblings of SIDS victims; and Group 3 consisted of neurologically suspect infants with apnea. The usual abundance and distribution of sharp EEG transients (SETs) were determined from 69 Group 1 infants. EEGs were interpreted as abnormal in the presence of ictal apnea, excessively abundant SETs, or immaturity of EEG background for conceptional age. Ninety percent of infants in Group 1 had entirely normal EEGs. There was no significant difference in the abundance or distribution of SETs between infants with normal breathing patterns and those with excessively periodic respirations. Nonictal apnea was recorded in 7% of Group 1 infants. The unexpected diagnosis of ictal apnea was confirmed in 2 Group 1 infants (1.2%), and 5 (2.9%) had excessive SETs but no recorded seizures. Only 4 infants (2.3%) had abnormally immature EEGs for conceptional age. Nonictal apnea occurred in 5 of 33 (15.2%) Group 3 infants and ictal apnea was confirmed in 2 others (6.1%). We conclude that the majority of Group 1 and 2 infants have normal cerebral cortical activity between and during apnea and that central nervous system cortical immaturity, as measured by EEG, plays no important role in the pathogenesis of SIDS. SETs are commonly recorded in these infants and must be conservatively interpreted. However, an EEG examination was critical in establishing the unexpected diagnosis of ictal apnea in a small percentage of Group 1 and 3 infants and materially influenced subsequent evaluation, management, and prognosis.