Closure of the ductus arteriosus and development of pulmonary branch stenosis in babies of less than 32 weeks gestation

AIMS

To define how often transient pulmonary branch stenosis (PBS) develops after closure of a patent ductus arteriosus (PDA) in babies born at less than 32 weeks gestation; to describe the natural history of PBS and the relation between PBS and a cardiac murmur.

METHODS

Fifty three preterm infants born at a gestational age less than 32 weeks and who had PDA diagnosed on echocardiography were recruited. An echocardiogram was performed on alternate days until the ductus arteriosus closed. If PBS was diagnosed, the baby was followed up until PBS resolved.

RESULTS

In 59%, PBS developed in one or both branches after closure of the PDA. In 21%, both pulmonary branches were affected. In 79%, the left pulmonary artery alone was involved but the right side was never affected alone. PBS had resolved in 74% by the time the infants reached 40 weeks, in 95% at a corrected age of 6 weeks, and in 100% at a corrected age of 3 months. There is a better correlation between a cardiac murmur and PBS than between a murmur and PDA.

CONCLUSIONS

PBS in preterm infants is usually not present at birth but develops after closure of a PDA. PBS resolves by a corrected age of 3 months. The presence of a murmur after closure of a PDA is usually related to PBS and not to reopening of the ductus arteriosus.

Investigating the role of context in learning to read: a direct test of Goodman's model

The much discussed 'whole language' or 'real books' approach to children's reading is based on a theory which makes two quite separate predictions: (1) that children will read difficult words more successfully in context than in isolation, and (2) that contextual experience of words will lead to greater improvements in word reading than isolated experience of words. We report a study which tests both predictions and supports the first but not the second.

Treatment and outcome of serious structural congenital heart disease

Serious structural congenital heart disease usually presents to the neonatal paediatrician, although increasingly these conditions are being diagnosed before birth. It is, therefore, important that those dealing with these fetuses and infants have some knowledge of their natural and modified history. The vast majority of lesions can either be corrected or given symptomatic palliation and this review discusses treatment options and provides up-to-date outcome information to enable fetal and neonatal staff to anticipate and to complement information given to families by paediatric cardiologists.

Cardiac tamponade after varicella infection

Infection with varicella zoster virus is common in childhood and generally associated with few complications. Myopericarditis following varicella infection is rare but may result in severe rhythm disturbances and congestive cardiac failure. The case is presented of a 4-month-old infant presenting with a large pericardial effusion and cardiac tamponade 2 weeks after the onset of a varicella exanthem. Although Streptococcus was noted in the pericardial fluid, it could not be grown on bacterial culture and the subsequent clinical course was in keeping with a viral myopericarditis.

CONCLUSION

Varicella infection in children may be complicated by myopericardial disease ranging from subclinical ECG changes to fulminant cardiac failure and/or cardiac tamponade. The clinical spectrum of this unusual complication is reviewed and the importance of early recognition emphasised.

Natural history of innocent heart murmurs in newborn babies: controlled echocardiographic study

AIM

To define the origin and the natural history of innocent heart murmurs in newborn infants.

METHODS

Fifty healthy babies born at term with the clinical diagnosis of an innocent heart murmur and 50 controls without a murmur were studied. Each baby had a complete two dimensional and pulsed Doppler echocardiogram and those with any abnormality were followed up at 6 weeks, 3 months, and 6 months until the murmur had disappeared or the heart was totally normal. Babies with congenital heart disease were excluded from the study.

RESULTS

Pulmonary branch stenosis (PBS) was found in 25 (50%) of the study group and in six (12%) controls; patent ductus arteriosus (PDA) in 30 (60%) subjects and in six (12%) controls; and a patent foramen ovale (PFO) in 50 (100%) subjects and in 41 (82%) controls. At 6 weeks the murmur had disappeared in 64% of babies. PBS was still present in eight of 22 (36%) babies at 6 weeks, in 12% at 3 months, but in none at 6 months. At 6 weeks, seven of the eight with PBS still had a murmur compared with two of 14 (14%) babies in which the PBS had resolved (P < 0.005). At 6 weeks the PDA had closed in all patients but the foramen ovale was still patent in 29 of 44 (66%) subjects and nine of 33 (27%) controls. The closure of the PFO was not influenced by its size at birth.

CONCLUSIONS

An innocent heart murmur in a baby born at term is often related to PBS, particularly if the murmur is still present after 24 hours of age, when most PDA have closed. At 6 weeks the murmur had disappeared and the PBS had resolved in 64% of the babies. PBS had resolved in all babies at 6 months.

Aortico-right ventricular tunnel

We report successful closure of an aortico-right ventricular tunnel in a 3-month-old infant with heart failure. One-year follow-up shows the child to be developing normally.

Cerebral blood flow velocity recordings and the prediction of intracranial haemorrhage and ischaemia

Doppler ultrasound was used to study prospectively cerebral and cardiovascular hemodynamics in a cohort of 120 preterm infants to see whether it was possible to predict infants at increased risk of developing cerebral pathology. The infants were divided into four outcome groups: Group I (n = 65, median gestation = 30 weeks) did not develop periventricular haemorrhage (PVH) nor periventricular leukomalacia (PVL) Group II (n = 43, median gestation = 28 weeks) developed PVH as the first or only cerebral lesion Group III (n = 7, median gestation = 29 weeks) developed PVL as the first or only cerebral lesion Group IV (n = 5, median gestation = 28 weeks) developed PVH and PVL simultaneously. Cerebral blood flow velocity (CBFV) and aorta blood flow velocity (ABFV) recordings made before the onset of PVH or PVL were compared between the four groups on each postnatal day but it was not possible to demonstrate a statistically significant difference between these variables in the four outcome groups. We conclude, therefore, that it is not possible to identify the infants who will go on to develop haemorrhage or ischaemic lesions on the basis of Doppler cerebral haemodynamic studies.