Factors relating to readmission of term and near-term neonates in the first two weeks of life. Early Discharge Survey Group of the Health Professional Advisory Board of the Greater New York Chapter of the March of Dimes.

AIMS: A multisite study of term and near term infants readmitted in the first two weeks of life to 9 New York City area hospitals in 1995 was conducted to evaluate factors related to readmission, including length of newborn stay. RESULTS: Of the 30,884 infants born at the 9 study hospitals 391 newborns were readmitted. The major admission diagnoses were infection, 40.7%, hyperbilirubinemia, 39.1%, and feeding and/or gastrointestinal problems, 10.5%. In the first week, 65.1% of readmissions were for hyperbilirubinemia and 19.1% were for infection or suspected sepsis. In the second week, 67.8% of readmissions were for infection and 7.6% were for hyperbilirubinemia. Hyperbilirubinemia was the most frequent diagnosis for White and Asian infants, while infection was most frequent for African-American and Hispanic infants. Age at readmission was younger and the interval from discharge was shorter for infants with hyperbilirubinemia. Abnormalities which should have precluded early discharge included feeding difficulties, cyanotic congenital heart defects, hemolytic disease of the newborn, early jaundice or early high bilirubin levels. CONCLUSION: Attention to identification of infants at risk and programs such as lactation counseling and universal screening for bilirubin (with appropriate interpretation) prior to discharge could have reduced the necessity for readmission regardless of the newborn length of stay.

Neonatal middle cerebral artery infarction: association with elevated maternal anticardiolipin antibodies.

A full-term neonate was born to a 41-year-old woman via elective primary cesarean section for frank breech presentation after a 41-week pregnancy. Starting at 6 hr of age the infant presented with multiple episodes of apnea and cyanosis, in association with moderate hypotonia, subsequently requiring assisted ventilatory support for 2 days. Computerized axial tomography of the brain revealed infarction in the distribution of the left middle cerebral artery. Magnetic resonance imaging of the brain showed a left middle cerebral artery territory infarct and also a small right posterior-temporal infarct. Magnetic resonance angiography of the head and neck was normal, however, inferring that the vascular infarction was peripheral in location. Maternal anticardiolipin antibodies were elevated. This is only the fifth reported case of cerebral infarction in a newborn in association with elevated maternal anticardiolipin antibodies.

Massive fetomaternal hemorrhage.

This report describes a full-term newborn with massive fetomaternal hemorrhage. Fetal movements were decreased 48 hr prior to delivery. On the day of delivery, they were absent. The nonstress test was abnormal with low biophysical profile and decreased beat-to-beat variability. The infant presented with extreme pallor, hypotonia, hepatosplenomegaly, and ascites. The initial hemoglobin was 2.2 g/dL, the Kleihauer-Betke stain was 27.6% (highest level ever reported). Right temporal and cerebellar hemorrhages were present. Sequelae include severe developmental delay and asymmetric double hemiplegia.

Water and salt conservation in the human fetus and newborn. I. Evidence for a role of fetal prolactin.

A study was performed on 94 women delivering at 34-44 weeks gestation, whose pregnancies were uncomplicated to determine the role of PRL in human fetal and neonatal salt and water conservation. Ultrasonic estimation of amniotic fluid (AF) volume and sampling of maternal blood, AF, cord blood, and 2-h neonatal blood were performed to analyze PRL, osmolality, sodium ion concentration ([Na]), and blood solids [hematocrit (Hct), total serum solids (tss), and total protein concentration]. In this report, which addresses the role of fetal PRL, Pearson correlations showed the following significant relationships: 1) approximation of cord serum osmolality and [Na] in cord and maternal serum, as well as parallel changes in cord blood Hct, tss, and total protein; 2) reduced estimated AF volume and increased AF osmolality in the face of elevated cord serum osmolality and [Na]; 3) a shift toward normal in cord Hct and tss over the first 2 h of neonatal life after an initially increased or decreased cord serum osmolality, [Na], Hct, or tss; and 4) relationship between fetal pituitary PRL levels of 230 micrograms/L or less and cord serum osmolality, [Na], and Hct. The entire range of cord serum PRL levels correlated with changes in AF osmolality and [Na] as well as with neonatal changes in Hct and tss. These findings support the hypotheses that osmotic equilibrium exists between maternal and fetal circulations; that disturbances in this balance lead to changes in fetal and neonatal water excretion; and that fetal PRL, stimulated by increases in cord serum osmolality and [Na], acts as an antidiuretic, leading to restoration of the offspring's extracellular fluid volume.

Congenital acquired immunodeficiency syndrome and congenital toxoplasmosis: pathologic support for a chronology of events.

We report a case of congenital acquired immunodeficiency syndrome (AIDS) with congenital opportunistic toxoplasmosis. The thymic histopathology was that seen in childhood AIDS cases and not that seen in primary congenital toxoplasmosis. The toxoplasma infection was selectively localized to the brain and the serum titers were paradoxically low as reported in most adult cases of AIDS with secondary infection by the parasite. These findings strongly suggest that the infection by the human immunodeficiency virus (HIV) preceded the toxoplasma infection in the fetus.

Vitamin A deficiency and pulmonary oxygen toxicity: morphometric studies in the murine lung.

Vitamin A and its precursor beta-carotene are naturally occurring antioxidants. The effects of diets deficient in beta-carotene and vitamin A on the alveolar-capillary membrane were studied in young adult BALB/C mice before and after exposure to 65% oxygen. One of three diets (standard complete, beta-carotene deficient, or beta-carotene and vitamin A deficient) was fed for a 6-wk period. Mice were then exposed to 65% oxygen for 0, 3, or 6 days, sacrificed, and their lungs examined by electron microscopy using the morphometric techniques of Weibel. The arithmetic and the harmonic mean thicknesses of the alveolar-capillary membrane and its components (epithelium, interstitium, and endothelium) were measured to assess the influences of diet and of duration of exposure to 65% oxygen. Analysis of variance and multiple comparisons of means (Student-Neuman-Keuls statistics) were applied. Diet alone did not significantly affect membrane thickness. However, duration of oxygen exposure increased the thicknesses of both the epithelium and interstitium in the group fed a diet deficient in both beta-carotene and vitamin A as compared to the other two groups although this was only significant for the epithelium. beta-Carotene deficiency alone did not affect the respiratory membrane either before or after oxygen exposure. These results suggest that vitamin A may be an important nutrient in the protection against pulmonary oxygen toxicity.

Intrapartum suctioning of meconium: comparative efficacy of bulb syringe and De Lee catheter.

Intrapartum suctioning of the newborn's pharynx with a De Lee catheter (DL) has reduced the incidence of meconium aspiration syndrome (MAS) in neonates born with meconium staining of the amniotic fluid. However, the bulb syringe (BLB) is used more often for this purpose because of greater technical convenience. In a prospective study, 60 offspring of such deliveries received intrapartum pharyngeal suctioning either by BLB (29 cases) or by DL (31 cases), according to random selection. The presence and amount of meconium in the trachea, incidence and severity of MAS, and mortality from the disease were similar between the two groups. This study suggests that the BLB is as effective as the DL for intrapartum removal of nasopharyngeal meconium in deliveries with meconium staining of the amniotic fluid. Since the BLB is easier to use, less expensive and probably safer, our results suggest that it may be the preferable method.

In utero-exposure to saccharin: a threat?

In-utero or immediate post-utero exposure of rats to saccharin results in an increased incidence of bladder tumors when compared to post-weaning exposure only. We studied 6 human mother-infant pairs following maternal intake of saccharin close to delivery. High performance liquid chromatography revealed the presence of saccharin in all 6 newborn cord sera as well as their mothers' sera and urine. This constitutes the first report of placental transfer of saccharin in humans. Despite the relative weakness in carcinogenicity of saccharin, this in-utero exposure, coupled with ex-utero exposure, may possibly contribute to an increased incidence of neoplasms.

Abdominal rescue after entrapment of the aftercoming head.

Entrapment of the aftercoming head during breech delivery is generally perceived as a complication that must be resolved by a vaginal extraction procedure. The successful rescue by classical cesarean section described in this report was performed for entrapment of the deflexed fetal head following delivery of the body and the arms.

Congenital melanocytosis with myelomeningocele and hydrocephalus.

We report an infant who had diffuse blue hyperpigmentation at birth, which rapidly progressed to gray, over the back, buttocks, and posterior aspect of the legs, and an associated congenital anomaly. The entire thickness of the dermis contained numerous very prominent melanocytic cells which, especially in the superficial dermis, were markedly dendritic, rather than merely fusiform. An epidermal melanocyte proliferation was also present. Histologically, the lesion thus differed markedly from a mongolian spot. We believe that diffuse hyperpigmentation in the neonate should call attention to the possibility of an associated neuroectodermal malformation.

Complete penoscrotal transposition.

A patient with complete penoscrotal transposition is described. We believe this represents the first such case associated with a chromosomal anomaly. A review of the literature is given.

Neonatal lupus erythematosus, multiple thromboses, and monoarthritis in a family with Ro antibody.

We describe a family afflicted with striking clinical and serologic autoimmune features. The mother and maternal uncle of a patient with neonatal lupus had rheumatic disease manifestations. All three had Ro antibodies (SS-A) in their sera, as well as La antibody (SS-B). The 17-year-old mother developed postpartum inflammatory monoarthritis of the right knee and had a positive lupus band test. The uncle at the age of 26 developed a fulminant disease most consistent with systemic lupus erythematosus (SLE); initial manifestations were myocardial infarction, deep vein thrombosis, and the nephrotic syndrome. Although it is known that mothers of neonatal lupus infants can develop SLE postpartum, the development of severe disease in the maternal uncle suggests the relevance of identifying seropositive relatives of individuals with neonatal lupus.