Effect of Nasal Continuous Positive Airway Pressure (NCPAP) Cycling and Continuous NCPAP on Successful Weaning: A Randomized Controlled Trial.

OBJECTIVE: To compare the effectiveness of nasal continuous positive airway pressure (NCPAP) cycling with continuous NCPAP in the successful weaning of preterm infants of 25(0)-28(6) wk gestation to nasal prongs. METHODS: A total of 30 infants with a gestational age (GA) of 25(0)-28(6) wk, ventilated for respiratory distress syndrome (RDS) and extubated to NCPAP were eligible for the study. They were randomized to NCPAP cycling [Group A: cycling between NCPAP of 4 cm and 1 liter per minute (LPM) of nasal prongs] or to continuous NCPAP at 4 cm of H2O (Group B). Primary outcome was successful weaning off NCPAP to nasal prongs at the end of 72 h of the intervention and remaining off NCPAP for the next 72 h. RESULTS: The demographic characteristics were similar in both the groups. Infants were randomized to Group A (n = 13) and Group B (n = 17). The primary outcome was not significantly different between the groups (successful weaning to nasal prongs: 31 vs. 41 %; p 0.71). CONCLUSIONS: In this pilot, feasibility study there were no differences in the rates of successful weaning of NCPAP to nasal prongs using either cycling NCPAP or continuous NCPAP in preterm infants. A need exists for a large randomized controlled trial (RCT) to determine the role of cycling NCPAP on neonatal outcomes.

Methemoglobin levels in umbilical cord blood of women with intrauterine growth restriction and preeclampsia.

OBJECTIVE: To measure nitric oxide (NO) levels, as assessed by methemoglobin (MetHb), in the umbilical cord arterial blood of women with preeclampsia (PE), normotensive pregnancies with intrauterine growth restriction (IUGR, <10th percentile for birth weight) and normotensive pregnancies with appropriate for gestational age (AGA) infants. DESIGN/METHODS: Prospective analysis of MetHb levels in umbilical arterial blood of pregnancies with PE, normotensive IUGR and normotensive AGA infants using spectrophotometry. Exclusion criteria included cigarette smoke exposure, hemolytic disorders, chronic hypertension, any significant medical illness and medications affecting NO or MetHb levels. RESULTS: There were 42 women in the PE, 42 in the AGA and 37 in the IUGR group. Maternal age, mode of delivery, gravidity, parity and infant gender were similar in the three groups. MetHb levels were significantly lower in the IUGR group compared to the AGA group (p < 0.01). MetHb levels, while higher in the PE group compared to the AGA group, did not reach statistical significance. CONCLUSION: Our data suggests that NO may play a key role in the pathogenesis of IUGR. We also, for the first time, provide information on umbilical arterial MetHb levels in PE, normotensive IUGR and normotensive AGA pregnancies.

Clinics in diagnostic imaging (132). Vein of Galen malformation.

A two-day-old, full-term male infant was admitted to the neonatal intensive care unit with heart failure. He was found to be non-dysmorphic, with no clinical evidence of sepsis. Physical examination was significant for hepatomegaly, active precordium, pansystolic murmur and hypotension requiring ionotropic support. A cranial bruit was detected on auscultation. Chest radiography revealed cardiomegaly and pulmonary oedema due to heart failure. Electrocardiogram and two-dimensional echocardiography were normal. Magnetic resonance imaging of the brain showed a large vein of Galen malformation, extensive cerebral ischaemia and multiple cerebral infarcts. This case illustrates the importance of auscultation of the cranium to rule out vein of Galen malformation, a potential cause of high-output cardiac failure in neonates in the absence of other common causes of heart failure.

Evaluation of the effectiveness of the standardized neonatal resuscitation program.

OBJECTIVE: To determine if health care personnel trained in the Neonatal Resuscitation Program (NRP) used the NRP guidelines in the resuscitation of newborn babies. To determine differences between self-reporting and documentation of resuscitation in medical records. STUDY DESIGN: Using a validated questionnaire, individuals participating in resuscitation of newborns voluntarily phoned and answered questions on an Interactive Voice Response (IVR) system. The study was undertaken in level II hospitals in Southern Alberta with 7500 deliveries per year. RESULTS: Of the 5155 babies delivered during the study, 16% required resuscitation (bag and mask ventilation 10.6%, intubation for meconium or intermittent positive pressure ventilation, IPPV, 3.6%, cardiac massage, CM, 0.3%, epinephrine 0.1%, naloxone 6.9%). Of babies whose interventions could be assessed, bag and mask was correct in 99%, endotracheal intubation for IPPV in 100%, and CM in 100%. Only 75% of babies had meconium managed correctly and 92% had naloxone administered according to guidelines. There were more instances where IVR (48) reported a procedure, which was not charted versus charted and not reported by IVR (21). Educational needs identified by IVR included skills of resuscitation and NRP indications for management. CONCLUSION: Bag and mask ventilation and intubation for neonatal resuscitation are more common than previously reported. Management of the meconium-stained baby and use of naloxone require further education. Compared to charts, use of IVR system allows more complete documentation with rationale of interventions and identification of continuing educational needs.

Combination of renal agenesis with respiratory and alimentary tract atresia results in normal lung development.

The VACTERL complex comprises renal agenesis and atresias of the alimentary and respiratory tracts. We report on a case with this combination causing severe oligohydramnios but with normal lung development. The likely protective mechanism for pulmonary development was an increase in alveolar pressure and reduced alveolar fluid loss due to the esophageal-tracheal malformation. This suggests the possible treatment of oligohydramnios by tracheal occlusion.

Prospective study of fluconazole therapy in systemic neonatal fungal infection.

BACKGROUND: Standard neonatal systemic antifungal therapy with amphotericin B and flucytosine can be associated with toxicity, drug resistance and the need for prolonged venous access. There is consequently a need for alternative treatment options. OBJECTIVES: To assess the efficacy and safety of fluconazole in the treatment of systemic neonatal fungal infections. METHOD: Open, nonrandomized evaluation of fluconazole treatment in 20 consecutively enrolled neonates with systemic fungal infection. RESULTS: Clinical and microbiologic cure was achieved in 12 of 19 (63%) of infants treated. One additional infant received prior amphotericin B therapy and is included for assessment of side effects. One infant with Torulopsis glabrata infection failed treatment. Six infants died of Gram-negative bacterial infection and other intercurrent medical problems. CONCLUSION: Fluconazole appeared to be safe and effective for treatment of systemic candidal infection in the neonate although more data are required in very low birth weight infants.

Serum triglycerides of breast milk-fed very-low-birth-weight infants.

Normative triglyceride levels were obtained from eighty-five infants weighing < 1500 g. At least 80% of their nutritional intake was their own mother's breast milk. Triglyceride levels did not correlate with birth weight, gestational age, volume of milk fed, age in days, or use of milk fortifier. The 95th percentile triglyceride value was 2.5 mmol/L. Assuming that breast milk-fed infants have triglyceride in the normal range, the acceptable limit of triglyceride values in very-low-birth-weight infants receiving i.v. lipids could be revised upward to 2.5 mmol/L.

Effect of educational program and interview on adoption of guidelines for the management of neonatal hyperbilirubinemia.

OBJECTIVES: To determine (a) whether physicians are adhering to the guidelines for the management of neonatal hyperbilirubinemia, (b) what influences their decisions to investigate and treat the condition and (c) the effect of an educational program and clinical recall interview on compliance with the guidelines. DESIGN: Retrospective chart audit. SETTING: Urban tertiary care hospital. PARTICIPANTS: All term neonates who received phototherapy but were not admitted to the neonatal intensive care unit. INTERVENTIONS: Educational program and clinical recall interview. MEASURES: Charts were reviewed from March to May 1986 (period I, before publication of the guidelines) and from November 1986 to January 1987 (period II, after publication and after the educational program). The audits were repeated from April to June 1989 (period III, during the interview phase) and from October to December 1989 (period IV, 6 months after the interviews). Two criteria determined the appropriate use of phototherapy: the serum bilirubin level and the postnatal day on which phototherapy was started. RESULTS: The proportion of infants receiving phototherapy for whom there were orders for complete blood counts to investigate hyperbilirubinemia increased from 20% in period I to 37% in period IV. The frequency of orders to determine the proportion of reticulocytes did not change significantly. The number of infants receiving phototherapy decreased over the study periods. The proportion receiving phototherapy in accordance with the criteria for the serum bilirubin level increased from 10% to 17% after the educational program (insignificant difference) and to 31% after the interviews (p = 0.02). Compliance with the guidelines was greater before the infants were 2 days old than when they were 3 days old or more (p = 0.01). Of the 45 physicians who prescribed phototherapy (for 94 infants) during period IV 26 never prescribed in accordance with the guidelines. The other 19 prescribed in accordance with the guidelines for 30 of 52 infants. Decisions to investigate and treat with phototherapy were affected by clinical and parental factors in addition to the guidelines. Two of the 25 physicians interviewed stated that the interview would influence their management of future cases of hyperbilirubinemia. CONCLUSION: A clinical recall interview can have a greater impact on changing physician management practices than factual communication on a group basis.

Spontaneous rupture of splenic artery aneurysm: maternal and fetal survival.

Because the diagnosis of ruptured splenic artery aneurysm in pregnancy is seldom made before operation, maternal and fetal mortality continues to be high. The authors describe the case of a 22-year-old woman who had a ruptured splenic artery aneurysm at 32 weeks' gestation. The attending obstetrician considered this condition in the differential diagnosis and it was confirmed by ultrasonography, leading to a successful outcome.

Normal newborns: special problems during the first three days of life.

Most newborns are admitted and managed in level 1 nurseries. Hypoglycemia, polycythemia, and jitteriness are three common clinical problems of these newborns, for which the family physician may request pediatric consultation. The authors discuss the definition, incidence, etiologies, clinical features, and the current diagnostic and treatment approach of these problems.

The management of post-term pregnancy.

Although post-term pregnancy is associated with an increased incidence of fetal distress, oligohydramnios, fetal macrosomia, fetal dysmaturity, and perinatal mortality, as many as 80% of post-term fetuses appear completely normal. The authors of this article discuss the three sub-groups of post-term pregnancies, and deal with the diagnosis and antepartum and intrapartum management of the condition. Recommendations and a protocol for management are provided.

Premature rupture of membranes.

The management of premature rupture of the amniotic membranes before 37 weeks gestation remains controversial. The authors of this article outline the risks involved for the fetus, define the various terms related, and discuss the antepartum and intrapartum management of such an event and offer a protocol that they have developed.

Suprapubic bladder aspiration in neonates.

Suprapubic bladder aspiration in neonates is a simple, safe, and useful technique for collection of sterile urine. The procedure can be performed in the hospital or office. Neither sedation nor local anesthetic is required. Suprapubic bladder aspiration of urine is the preferred method of collecting urine for culture in septic neonates. The technique is also indicated to verify urinary tract infection in neonates. Suprapubic bladder aspiration is contraindicated in the presence of abdominal distension or an empty bladder. Carefully and properly performed, the risk of complications should be negligible, and the success rate in obtaining urine is 90%.

Association of cholelithiasis with total parenteral nutrition and fasting in a preterm infant.

Cholelithiasis is uncommon in infants. A case of cholelithiasis in a preterm boy who required total parenteral nutrition (TPN) because of prolonged fasting is described. The diagnosis was confirmed by ultrasonography. Despite cholestasis, reintroduction of oral feeding and discontinuation of TPN resulted in the spontaneous disappearance of the gallstones.

Group B streptococcal septicemia and delayed-onset congenital right-sided diaphragmatic hernia.

A case is reported of fulminant early-onset group B streptococcal septicemia and delayed-onset congenital right-sided diaphragmatic hernia in a neonate. The latter condition should be considered when early-onset group B streptococcal disease is followed by increasing respiratory distress, right-sided pleural effusion and partial or complete opacification of the right side of the thorax.

Comparison of low and high sodium and potassium content in oral rehydration solutions.

PIP: Oral rehydration solutions (ORS) with low and high sodium or potassium contents were compared in 84 infants aged 3-15 months with dehydration caused by acute watery diarrhea. In randomized, double-blind trials, the ORS contained (in mmol/liter): glucose, 110; HCO3, 30; K, 10; Na, 60 (low) or 90 (high), or, in a second trial, the high Na formula plus 20 vs. 35 mEq/liter of K and extra oral water, given in the ratio of 2 bottles (240 ml) of ORS followed by 1 bottle of plain water (the 2:1 regimen). The balance technique was used to measure net absorption. Of the 84 infants, only 1 required intravenous therapy. During the first 6 hours of therapy, mean sodium absorption was significantly lower in the low Na group, and hyponatremia was more common. A few high Na group infants receiving no extra oral water had transient mild asymptomatic hypernatremia. Mean K absorption from 0-6 hours was significantly higher in the high K group, and they had no hypokalemia after oral rehydration; in contrast, 33% of the low K infants had hypokalemia. High Na ORS in the 2:1 regimen caused no electrolyte abnormalites, yielded better sodium absorption, and was usable in all age groups and for all diarrheas. High K ORS corrected K deficits better than the low K ORS. An increase in potassium concentration above that in the currently recommended ORS formula should be considered.^ieng