Blood spot glucocorticoid concentrations in ill preterm infants

The adrenocortical response to stress was studied longitudinally in 10 ill preterm infants using measurements of cortisol and 170H-progesterone concentrations in filter paper blood spots. Mean cortisol and 170H-progesterone concentrations reached a peak of 2200 nmol/l and 65 nmol/l, respectively, between the third and fifth days of life. These concentrations far exceeded those observed in older children and adults subjected to stress as a result of surgery. Further pulses of endogenous cortisol production of 4000 nmol/l or more occurred in association with clinical complications such as intraventricular haemorrhage. These results indicate that infants undergoing intensive care are unduly stressed. Consideration should be given to providing enough sedation and appropriate analgesia for ill preterm infants during painful procedures such as insertion of venous cannulae and arterial puncture.

Birthweight-specific risk factors for necrotising enterocolitis

In a multicentre case-control study of necrotising enterocolitis risk factors were found to vary with birthweight of cases. In very low birthweight cases the risk factors identified were those associated with prolonged or recurrent hypoxia (recurrent apnoea, respiratory distress, assisted ventilation, and umbilical artery catheterisation). In heavier birthweight infants the risk factors were, in contrast, related to hypoxia at birth (low 1 minute Apgar score and endotracheal intubation at birth) and umbilical vessel catheterisation used in exchange transfusions. Contradictory findings in published case-control studies carried out in the USA may be due to differences in patient populations and management policies. Hypoxia and umbilical vessel catheterisation should still be considered as risk factors for necrotising enterocolitis.

Assessment of adrenocortical activity in term newborn infants using salivary cortisol determinations

Salivary cortisol concentrations were collected every 2 hours over a 24-hour period in eight healthy 2-day-old term neonates. Two maxima in cortisol output were noted, neither being related to the time of day or time since birth. Salivary cortisol concentrations ranged from 2.5 to 57.4 nmol/L (0.09 to 2.08 micrograms/dL), and throughout the 24 hours showed considerable variation (21% to 42%) not related to the state of arousal. The validity of the method was confirmed by collecting matched plasma and saliva samples from another group of 36 neonates. The correlation between plasma and saliva cortisol was r = 0.83. We suggest that salivary cortisol is a useful, noninvasive method of studying adrenocortical status in the newborn infant.

Multicentre trial of ethamsylate for prevention of periventricular haemorrhage in very low birthweight infants

The effectiveness of ethamsylate in the prevention of periventricular haemorrhage (PVH) in very low birthweight infants was evaluated by means of a multicentre, placebo-controlled, double-blind trial. In 330 infants without evidence of PVH on initial cranial ultrasound examination there was little difference between ethamsylate and placebo groups with respect to subependymal haemorrhage, but intraventricular and parenchymal haemorrhages developed in 30/162 infants (18.5%) in the treated group, compared with 50/168 (29.8%) in the control group (p less than 0.02). The incidence of intraventricular and parenchymal haemorrhage in survivors was 20/137 (14.6%) in the ethamsylate group and 37/146 (25.3%) in the controls (p less than 0.05). In 30 infants with evidence of PVH on the initial scan, ethamsylate treatment seemed to limit parenchymal extension. Analysis of the total cohort of 360 infants showed that the proportion of infants in whom an increase of two or more grades of severity of PVH was recorded during the trial was lower in the treated than in the placebo group (p less than 0.01). No adverse effects were attributed to ethamsylate therapy. The reported incidence of patent ductus arterious was lower in the treated than in the placebo group (p less than 0.02). Mortality was similar in the two groups.

Plasma alkaline phosphatase activity and its relation to rickets in pre-term infants

Sequential measurements of plasma alkaline phosphatase activity were made in 84 pre-term infants delivered before 38 weeks gestation. In 67% of infants, without evidence of rickets but in whom three or more measurements were made and the peak activity was less than 10 times the adult reference range, the activity rose to a peak and declined to previous levels, or lower. The time taken for these changes varied greatly. The range of values was inspected at each week of age, and in all but six cases the level did not exceed 10 times the upper limit of the adult reference range. Three infants had radiological evidence of rickets, and of the six cases in whom higher levels were found, only one had radiological evidence of rickets; the remainder did not. It is recommended that in the latter, the high plasma alkaline phosphatase activity should be regarded as evidence of subclinical bone disease.

A proposal for tracking health care for the homeless

The number of homeless in the nation has increased rapidly during the first half of this decade. These two million homeless individuals are at high risk for health problems since they lack the essentials to remain healthy. Several large cities have developed and implemented health care programs to alleviate the problem of the homeless in America. However, most of these programs have been instigated solely by health care providers who have differing goals, values, and beliefs about health care than those they purport to serve. These differing perspectives give rise to an array of health care utilization/accessibility problems including coordination and continuity of care. To address some of these problems of coordination, a Tool for Referral Assessment of Continuity (TRAC) has been developed for assisting a complex health care system in the referral and tracking of homeless clients. A description of the TRAC is included here.

Relation of haemoglobin levels in first and second trimesters to outcome of pregnancy

The relation between haemoglobin (Hb) concentrations at antenatal booking and subsequent outcome was examined in 54 382 singleton pregnancies. Both high (greater than 13.2 g/dl) and low (less than 10.4 g/dl) Hb values were associated with an adverse outcome. Mothers with a booking Hb in the intermediate range (10.4-13.2 g/dl) fared best. Significant differences emerged in perinatal mortality between those with high and those with intermediate Hb levels at 13-19 weeks' gestation. The frequencies of perinatal death, low birthweight, and preterm delivery were greater with high than with intermediate Hb. There was a striking relation between booking Hb values and the subsequent frequency of hypertension (p less than 0.001). In primiparas, the frequency of subsequent hypertension ranged from 7% at Hb values under 10.5 g/dl to 42% at Hb concentrations over 14.5 g/dl.

Cotside EEG monitoring using computerised spectral analysis

The application and interpretation of computerised spectral analysis of the neonatal electroencephalogram (EEG) using the Neuroscience Berg Fourier Analyser (BFA) is described. Recordings are immediately available at the cotside. Electrophysiological changes can be recognised by individuals with no previous experience in EEG technology. The compact nature of the analysis allows long periods of recording to be viewed within minutes. In addition to the unequivocal demonstration of both clinical and subclinical seizures, the BFA is useful in the evaluation of interseizure activity--that is, disturbance of sleep patterns, electrical output, and hemisphere asymmetry.

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.

Cardiovascular and metabolic effects of cervical epinephrine infiltration

Ventricular arrhythmia may follow the infiltration of dilute, epinephrine-containing solutions to achieve hemostasis during surgery. The objective of this study was to determine the cardiovascular and metabolic changes associated with the infiltration of 1.5 micrograms/kg epinephrine 1:200,000 in 0.5% lidocaine into the cervix of patients having a cervical cone biopsy under epidural anesthesia. These observations were compared with a control group who were infiltrated with 0.5% plain lidocaine under similar epidural anesthesia during cone biopsy. In the epinephrine-treated group, marked heart rate, rhythm, and systolic/diastolic blood pressure changes from baseline values were observed as well as significant glycogenolysis, lactic acidosis, and hypokalemia. Based on these observations, the total dose of injected epinephrine should be less than 1 microgram/kg; the solution should be diluted to 1:400,000 concentration, and the injection, after careful aspiration, should be performed over at least five minutes into the less vascular anterior and posterior cervix sites.

Neutralising antibody against type 1 and type 2 herpes simplex virus in cervical mucus of women with cervical intra-epithelial neoplasia

Patients with cervical intra-epithelial neoplasia had significantly increased neutralising antibody activity to type 2 herpes simplex virus in the cervical mucus. While patients differed from control subjects with respect to their number of sexual partners and socio-economic class, there were significant differences in neutralising antibody activity for case control comparisons within the same number of sexual partners or socio-economic groupings. The results lend support to the putative association between type 2 herpes simplex virus infection and pre-invasive and invasive carcinoma of the uterine cervix.

Zinc deficiency: a problem with preterm breast milk

We report a breast-fed preterm infant (31 weeks gestation) who developed nutritional zinc deficiency 13 weeks post delivery. Serial samples of his mothers breast milk from early lactation (2 weeks post delivery) contained very low zinc concentrations, although her serum zinc and sweat zinc concentrations were normal. Following the birth of her second baby at 38 weeks gestation, her breast milk contained normal amounts of zinc. We conclude that the low breast milk zinc values obtained following the first pregnancy may have been due to immaturity of the milk. Units that feed very low birth-weight babies preterm milk should check its zinc concentration or at least have a high index of suspicion for this nutritional deficiency.

Obstetric analgesia, anaesthesia and the Apgar score

This study examines the changing pattern of maternal analgesia administration during the decade 1970-1979. In addition, the relationship between analgesia, anaesthesia and the infant's Apgar score was documented. Approximately 40000 deliveries to South Glamorgan residents were included in the study. Over the two quinquennia 1970-1974 and 1975-1979 the administration of epidural block increased from 5.6% to 17.5%. The Apgar score of babies in the epidural block group was significantly better in the latter period. Respiratory depression following Caesarean section remains a problem. The group delivered by elective Caesarean section contained a substantial proportion of infants with a low Apgar score; 30% had an Apgar score less than 8 and 10% had a score of less than 4. Likely causative factors include undue sensitivity of the infants' respiratory centre and aortocaval compression during surgery.

Employment in pregnancy: prevalence, maternal characteristics, perinatal outcome

Data from the Cardiff Births Survey was used to examine the relation between the nature of employment and perinatal outcome. The proportion of all expectant mothers who work during pregnancy increased from 38.7% in 1965/69 to 43.9% in 1975/79 (p less than 0.001). The percentage of working primiparas, however, remained unchanged at approximately 80%, whereas the percentage of working multiparas rose from 15.1% to 22.1%. The non-employed primiparas were more likely than the employed primiparas to be at the extremes of maternal age, to have a history of medical problems and previous abortions, and to attend less often for antenatal care. Perinatal outcome (measured in terms of perinatal mortality, birthweight, and length of gestation) was significantly better among the employed mothers. Non-employed mothers in social classes I and II seemed to be a particularly high risk group. Exclusion of mothers with an adverse obstetric or medical history considerably reduced the differences in perinatal outcome between the two groups. The findings suggest that healthy women without an adverse obstetric or medical history can safely continue in employment during pregnancy.

Planned and unplanned deliveries at home: implications of a changing ratio

The observation that perinatal mortality among babies delivered at home has tended to increase beyond that among babies delivered in consultant obstetric units has caused alarm and prompted recommendations that delivery at home should be further phased out. With data derived from the Cardiff Births Survey the possibility was investigated that this trend might reflect a changing ratio of planned to unplanned domiciliary births. At the beginning of the 1970s deliveries at home that were planned to be so outnumbered those that were not by nearly five to one. By 1979 unplanned deliveries at home outnumbered planned deliveries. The characteristics of the mothers, the health care they received, and the outcome of delivery differed strikingly between planned and unplanned deliveries at home. It is concluded, firstly, that every year the maternity services must try to meet the various needs of about 2000 women in England and Wales who give birth at home without planning to do so; and, secondly, that the heterogeneity of births at home and in hospital will continue to obstruct the search for unbiased estimates of the risks attributable to delivery in specialist obstetric units, general practitioner units, and at home.

Oesophageal candidiasis and croup in a child with defective neutrophil motility

Severe oesophageal candidiasis and croup due to involvement of the larynx developed insidiously in a girl aged 20 months. There had been delayed separation of the umbilical cord and repeated infections associated with a defect of neutrophil motility. The significance of the early clinical features was not fully appreciated and the diagnosis considered only when stricture of the oesophagus became evident. She was treated with oral ketoconazole 100 mg daily. After one month's treatment there was striking radiological improvement apart from the persistence of the oesophageal stricture. The croup resolved completely but there was only partial relief of dysphagia because of the residual stricture. We would emphasis that candidiasis should be anticipated and treated vigorously in children with such a defect of neutrophil motility.