National guidelines for treatment of jaundice in the newborn.

UNLABELLED: Jaundice is the most common reason for instituting treatment in otherwise healthy as well as sick newborn infants. Herein, we describe the process employed in Norway to forge agreement on a set of treatment guidelines that are now used across the country. The Norwegian Pediatric Association was a key resource in this process, which involved contacts with all paediatric departments in Norway. We have also performed an international survey regarding the use of such national guidelines, showing that the majority of those queried confirm having national guidelines. The evidence base for any neonatal jaundice guideline is weak; therefore, it is not surprising that the various guidelines differ both in format and in specifics. In the Norwegian guidelines, treatment indications are based on bilirubin concentrations and related to birth weight. Postnatal age is also factored in because jaundice develops gradually during the first 3-4 days before it levels off. CONCLUSION: Following the introduction of these guidelines, fewer babies in Norway receive phototherapy, and no cases of chronic kernicterus have been reported during this period.

Bronchopulmonary dysplasia - prevalence, severity and predictive factors in a national cohort of extremely premature infants.

AIM: To study prevalence and predictive factors of bronchopulmonary dysplasia (BPD) in a cohort of preterm infants with a high incidence of prenatal steroid and surfactant treatment. METHODS: BPD was analysed in a national cohort of infants with gestational age (GA) of 22-27 completed weeks (wks) or birth weight (BW) of 500-999 g. Of 464 infants who were transferred to a NICU, 377 infants with GA ≤ 30 wks and survived beyond 28 days were included in the study. RESULTS: Moderate or severe BPD was strongly related to GA. Of infants with GA 22-25 wks, 67.3% developed BPD compared to 36.6% at GA 26-30 wks. Overall, moderate and severe BPD was significantly more common in boys (63.3%) than in girls (36.6%) (p = 0.0004), but female gender was not a protective factor in infants with GA 22-25 wks. In multivariate analyses, BPD was significantly associated with gender, surfactant treatment and treatment for PDA. CONCLUSIONS: BPD remains a severe complication of extreme prematurity in spite of prenatal steroids and surfactant treatment. Whether associations with surfactant and PDA treatment simply reflect severity of early lung disease or have causal relationships should probably be studied in randomized controlled trials.

Anogenital human papillomavirus in non-abused preschool children.

AIM: To estimate the prevalence of human papillomavirus (HPV) in anogenital samples from children selected for non-abuse. METHODS: A letter of invitation was sent to 2731 girls and 1042 boys, all of them aged 5 or 6 y. Inclusion was based on self-selection, whereby parents who did not suspect any occurrence of sexual abuse of their child gave informed consent to participate. Several mechanisms were undertaken to exclude abused children. A complete examination was done of each child, including anogenital examination with a colposcope and microbiological sampling from the genitals and anus. Polymerase chain reaction (PCR) using primers MY09 and MY11 was used to identify HPV, and sequencing was done on each positive amplicon. RESULTS: PCR was performed on 325 adequate specimens from 211 children enrolled. Seven samples from 5 girls were HPV-positive, making 2/161 (1.2%) of the anal and 5/164 (3.0%) of the genital specimens positive. HPV was not detected in any of the boys. In four girls strong associations with HPV 6 genotypes were found, while one girl probably had a mixed infection with HPV 6 and 16. Three girls (1.8%) had clinically detectable anogenital warts. CONCLUSION: Since our results are comparable with a prevalence reported from allegedly abused children, and higher rates have been reported from the oral cavity in healthy children, we find detection of HPV unreliable as an indicator of sexual abuse in 5-6-y-old children. The rate of anogenital warts found in our study is comparable with a rate reported in abused children.

Genital anatomy in non-abused preschool girls.

AIM: To describe the normal variations in genital anatomy in preschool girls selected for non-abuse. METHODS: A total of 2731 girls aged 5 or 6 y were invited to take part in the study; 195 girls were recruited. Inclusion was based on self-selection, whereby parents who did not suspect any occurrence of sexual abuse of their children gave informed consent to participate. Several steps were taken to exclude abused girls and girls with previous accidental genital injuries. The genital examination, using a colposcope and a camera, was performed in supine position using a separation and traction technique, and in the prone knee-chest position. RESULTS: A number of genital anatomical features and hymenal measurements were described and found consistent with previous studies. An important finding was outward folding of the posterior hymenal rim in many girls, a feature that could be difficult to distinguish from attenuation of the posterior hymen. A gaping hymenal orifice, previously suggested to be a supportive sign of sexual abuse, was fairly frequently found and significantly associated with a large horizontal hymenal diameter. CONCLUSION: To distinguish between girls with outward folding of the posterior hymen and those with attenuated hymens, we recommend the use of the saline irrigation method. Even though normative hymenal measurement data now exist from a reasonable number of girls, these measurements should be used with caution in sexual abuse evaluations.

Anogenital bacteriology in non-abused preschool children: a descriptive study of the aerobic genital flora and the isolation of anogenital Gardnerella vaginalis.

The purpose of the study is to describe the genital aerobic bacterial flora including Gardnerella vaginalis in girls and the occurrence of anal G. vaginalis in both genders. From a group of 3773 children, 278 (99 boys and 179 girls) with a mean age of 5.63 y (range: 5.13-6.73) were recruited. Inclusion in the study was based on self-selection, whereby parents who did not suspect any occurrence of sexual abuse of their child gave informed consent to participate. Several mechanisms were undertaken to exclude abused children. At least one bacterial species was isolated from the genitals of 59 (33.9%) girls. Most isolates (39 out of 99) were bacteria representing skin flora (staphylococci and coryneform organisms), with viridans streptococci and related organisms as the second most common group of isolates (31 out of 99). S. anginosus was the single most frequent bacterial species identified (17 isolates). Streptococcus pyogenes was isolated from the genitals of two girls, Streptococcus pneumoniae from one girl and Haemophilus influenzae from eight girls. G. vaginalis was not isolated from the genitals in any girl, but the organism was isolated from the anal canal in three children.

Perianal anatomy in non-abused preschool children.

UNLABELLED: The purpose of this study was to describe the normal variation in perianal anatomy in preschool children, selected for non-abuse, and to compare the findings in two examination positions. A letter of invitation was sent to 3773 children, after which 305 children (103 boys and 202 girls) were recruited. Inclusion in the study was based on self-selection, whereby parents who did not suspect any occurrence of sexual abuse of their child gave informed consent to participate. The mean age of the children was 5.63 y (range: 5.13-6.75). An anal examination was performed in the left lateral position (LLP) and the prone knee-chest position (KCP), for approximately 30 s each. A colposcope and a camera were used. All data were systematically analysed for gender differences, and a paired sample test was used to compare findings in LLP and KCP. Venous congestion in LLP and external anal dilatation in both positions were significantly more common in girls, while midline depressions and smooth areas (both positions) were significantly more common in boys. External and total anal dilatation, midline smooth areas and depressions and the occurrence of a prominent anal verge were significantly more common in the KCP. The finding of total anal dilatation was rare. CONCLUSION: We observed several gender and position differences in perianal anatomy, and most of these findings seem to be related to structure and tone in the anal muscles.

Criteria for treatment of neonatal jaundice.

Treatment of neonatal hyperbilirubinemia is usually based on the measurements of total serum bilirubin levels. Based on empirical data, it is generally recommended to start phototherapy at lower levels in low birth weight and very low birth weight infants than in term infants, but no general agreement exists on exact limits. Treatment criteria in preterm infants do not, however, have the same empirical backing as in term infants. The very low and extremely low birth weight infants are more susceptible to bilirubin toxicity. However, bilirubin may function as an antioxidant and enzyme inducer in these infants. Several other different approaches to establish treatment criteria have also been suggested, and a summary of these are presented and discussed. With the exception of measurement of unbound bilirubin, very few of these approaches have been validated in routine clinical settings. However, unbound bilirubin is at present mainly used also as a parameter to be evaluated in relation to total bilirubin values. The present treatment criteria result in a considerable overtreatment particularly of term infants. However, with a more relaxed attitude toward neonatal hyperbilirubinemia by health care professionals, kernicterus is again reported in term infants. Because the basic mechanisms of bilirubin toxicity as well as the relative significance of the maximum serum bilirubin level compared to the duration of hyperbilirubinemia are not known, individual assessment of a newborn infant's tolerance for hyperbilirubinemia is difficult. Major changes in the empirically developed criteria for treatment of hyperbilirubinemia in the newborn are therefore not justified in the near future. For term infants, the search for validated criteria for follow-up of jaundiced infants after discharge are therefore more important than revision of existing criteria for phototherapy.

[Manpower resources and patient treatment at a regional hospital]. / Personellressurser og pasientbehandling ved et regionsykehus.

BACKGROUND: Significant increases in hospital budgets over the last few years have not resulted in a comparable increase in patient volume. MATERIAL AND METHODS: The increase in hospital admissions, surgical procedures and outpatient care from 1995 to 1999 at a large regional hospital was compared to the increase in hospital staff numbers over date same period. RESULTS: While admissions were up 6.3%, surgical procedures 3.3% and outpatient consultations 6.7%, the overall increase in staff numbers was 12.0%. The number of physicians was up by 30.6%, that of nurses by 13.1%. Secretarial/administrative and technical staff numbers also increased significantly more than the patient population. The data showed that each group of health care workers had a significant overall decrease in productivity, defined as consultations/examinations per head. However, several departments broke this trend; they showed increases in productivity, i.e. that the increase in patient-related activities greatly increased the increase in staff numbers. INTERPRETATION: Further analysis of how departments that manage to increase productivity are organised and how they plan their activities could give information that would be of value to other departments and units. Hospital productivity and effectiveness are probably more related to management at the patient level that to superior top management or to the ownership structure of the hospital.

Fifty-Hertz magnetic field exposures of premature infants in a neonatal intensive care unit.

In this study the magnetic flux density in and around incubators of a neonatal intensive care unit was registered and mapped. The mean 50-Hz magnetic flux densities in an incubator were typically in the range of 0.2-1 microT, with maximum values around 1.5 microT. For 1 incubator, harmonics contributed to the field substantially. The field levels varied depending on the type of equipment, the positioning of the electronics and the position of the 240-volt main plugs. The positioning of the infant in the incubator and the precise mattress position in the incubator affected the magnetic flux density to a great extent, as did the positioning of the electronic monitoring and treatment equipment. The flux density values found were fairly low as compared to magnetic field levels present at some work places where high electric currents are used. In intensive care units, however, the duration of exposure can be very long, especially for premature infants. The fields can also be compared with the magnetic field levels of residences and are then approximately 100 times higher. Further studies are necessary -it seems important to record magnetic fields and attempt to reduce the levels. Such a reduction can be achieved by reducing the field from the incubators but also by changing the electronic equipment around the incubators or increasing the distance to the incubator. Further research should of course also study any mechanism by which magnetic fields can affect cells and organisms. Compared to the risks many of these infants are exposed to, it is difficult to say whether the magnetic field levels measured can represent a significant additional risk factor. However, this is an area where one should adopt a prudent avoidance strategy, particulary considering how easily these fields can be reduced, mainly through redesign of the various equipment.

Cardiopulmonary function in premature infants with bronchopulmonary dysplasia--a 2-year follow up.

Twenty-three premature infants (GA 28.8 +/- 0.5 weeks) with bronchopulmonary dysplasia (BPD) and 14 premature infants (controls, GA 33.0 +/- 1.2 weeks) with moderate respiratory distress syndrome or with mild respiratory disturbances, were evaluated for impairment of cardiopulmonary function at 50 and 120 weeks corrected age. Respiratory system compliance was reduced in both groups, but improved with advancing age. Respiratory system resistance was initially increased, especially in the BPD group, but improved gradually. Maximum flow at functional residual capacity (VmaxFRC ml/s) indicated, nevertheless, severe peripheral obstruction (flow < 84 ml/s) in 16/20 of infants with BPD and in 7/12 of control infants at 50 weeks corrected age. At 120 weeks corrected age none of the control patients had severe peripheral pulmonary obstruction (flow < 120 ml/s), while this was still found in 5/13 infants with BPD. Doppler echocardiography indicated cardiac involvement (shortened pulmonary acceleration time) in patients with the most severe peripheral pulmonary obstruction. Pulmonary morbidity was also higher in the BPD group, and these infants were shorter and weighed less than the control infants. CONCLUSION. Measurements of maximum flow at functional residual capacity as well as cardiac evaluation are essential elements in follow up of infants with severe BPD.

Retinal and choroidal blood flow response to hyperoxemia after severe hypoxemia in the newborn piglet.

To investigate the effect of hyperoxemia on the ocular circulation after a severe hypoxemic insult (8% O2 until base excess reached -20 mmol/l), we randomly reoxygenated newborn piglets with 100% (study group, n = 8) or 21% O2 (control group, n = 10). Retinal (RBF) and choroidal blood flow (ChBF) were measured with radioactive microspheres. The hypoxemic insult did not change RBF, while ChBF significantly decreased. However, a marked reduction in both retinal (RDO2) and choroidal oxygen delivery (ChDO2) was observed, probably resulting in hypoxia both in the inner and outer retina. At 5 and 20 min of reoxygenation a similar hyperemic response in the retina was seen in both groups. RDO2 also increased significantly and no significant differences between the 2 groups could be demonstrated. We found no indication of retinal vasoconstriction during hyperoxemia. We speculate that the vasodilating effect of the preceding hypoxemia overrules the vasoconstrictive effect of the retinal vessels normally found during hyperoxemia.