Safety and efficacy of a topical anesthetic for neonatal circumcision.

OBJECTIVE: Circumcision is a common neonatal surgical procedure routinely performed without the use of anesthesia. The purpose of this study was to evaluate the safety and efficacy of topical lidocaine cream as an anesthetic for circumcision. METHODS: Thirty newborns were studied in a randomized, double-blind, placebo-controlled study; 15 received a topical 30% lidocaine cream and 15 received the cream base alone. Vital signs were recorded, and preoperative and postoperative serum beta-endorphin and lidocaine concentrations were measured. A videotape of the newborn was used to score behavioral changes. RESULTS: Comparisons of the vital signs precircumcision and postcircumcision showed no differences between the placebo and treatment groups, with the exception of mean systolic blood pressure, which significantly increased in the placebo-treated newborns (P < .05). Serum beta-endorphin concentrations increased postoperatively in 11 of 15 subjects receiving placebo, but decreased or remained unchanged in 10 of 15 subjects receiving lidocaine (P = .03, Fisher's exact test). When stress-related behaviors in the precircumcision and post-circumcision periods were compared, the mean increase in their occurrence was greater in the placebo than in the treatment group. There was no significant absorption of lidocaine as measured in the serum. CONCLUSION: Topical application of a 30% lidocaine cream as used in this study may be a safe and efficacious anesthetic for circumcision.

Impact of a Resource-Based Relative Value Scale fee schedule on reimbursements to neonatologists.

We investigated the possible effect of the Resource-Based Relative Value Scale (RBRVS) fee schedule on reimbursements for neonatologists. This payment system may prove attractive to most third-party payers and is predicted to result in lower procedural reimbursement, which is a significant component of neonatal care. We studied the charges and reimbursements for the portion of our intensive care nursery patient population covered by Medicaid for a 1-year period. Total, procedural, and nonprocedural reimbursements under three current systems and the RBRVS were compared. The RBRVS system produced overall improved reimbursement compared with Medicaid, but decreased reimbursement compared with the other two systems. Nonprocedural services were relatively better reimbursed than procedural services. The impact of RBRVS will depend on the population mix of third-party payers, the proportion of nonprocedural charges in a particular neonatal intensive care unit, and the conversion factor used by the third-party payer.

Hypomandibular faciocranial dysostosis: report of an affected sib and follow-up.

Hypomandibular faciocranial dysostosis is a condition heretofore described only in a single case. We report the birth of an affected sister along with follow-up information on the initial surviving patient. While a primary error in neural crest development was postulated in this syndrome, subsequently discovered anatomical abnormalities suggest a more complex pathogenesis.

Improved survival and neurodevelopmental outcome for infants less than 801 grams birthweight.

We reviewed the perinatal management and subsequent outcome of infants 401 to 800 gm birthweight delivered in 1983 to 1985 compared with those born in 1980 to 1982. Intrapartum fetal heart rate monitoring, cesarean section delivery, attempted delivery room resuscitation, and 5-minute Apgar scores greater than 5 were more frequent in 1983 to 1985. Significantly greater neonatal survival was evident for infants 500 to 700 gm birthweight (31%) and 24 to 27 weeks' gestation (45%) in 1983 to 1985, p less than 0.005. Infant birthweight, gestational age, gender, and 5-minute Apgar score, in addition to intrapartum tocolysis use, were predictors of higher survival by stepwise discriminant analysis. At a mean follow-up of 27 months, 13% (6 of 46) born in 1983 to 1985 had major disability compared with 67% (6 of 9) of infants born in 1980 to 1982. There has been a significant increase in survival and improvement in neurodevelopmental follow-up status for infants less than 801 gm birthweight. These improved outcome data should be considered by caregivers providing perinatal management and counseling parents regarding extremely low birthweight infants.

Cardiac output determinations in the newborn. Reproducibility of the pulsed Doppler velocity measurement.

Cardiac output (QAo) can be estimated noninvasively by pulsed Doppler (PD) ultrasonographic determination of mean ascending aortic blood flow velocity (VAo) combined with M-mode echocardiographic determination of ascending aortic cross sectional area (AAo). Cardiac output is calculated from the volumetric flow equation (QAo) = (VAo) X (AAo). Pulsed Doppler measurements are known to correlate well with Fick and thermodilution methods; however, inter- and intraoperator variability of the velocity component of the PD method has not been determined in newborns. We did three repeated PD measures of mean aortic flow velocity in ten term infants (using four trained operators) to determine inter- and intraoperator reproducibility. The coefficient of variation for intraoperator variability (random error) for a single measurement of VAo was 11.7%. If three repeated measures by a single operator were averaged, the random error was 7.0%. There was little interoperator variability found.