Using topical benzocaine before lingual frenotomy did not reduce crying and should be discouraged.

AIM: The US Food and Drug Administration has said that oral preparations containing benzocaine should only be used in infants under strict medical supervision, due to the rare, but potentially fatal, risk of methemoglobinemia. This study aimed to determine the analgesic effect of topical application of benzocaine prior to lingual frenotomy in infants with symptomatic tongue-tie. We hypothesised that the duration of crying immediately following frenotomy with topical benzocaine would be shorter than with no benzocaine. METHODS: This randomised controlled study compared the length of crying after lingual frenotomy in term infants who did, or did not, receive topical application of benzocaine to the lingual frenulum prior to the procedure. RESULTS: We recruited 21 infants to this study. Crying time was less than one minute in all of the subjects. The average length of crying in the benzocaine group (21.6 ± 13.6 sec) was longer than the length of crying in the control group (13.1 ± 4.0 sec), p = 0.103. CONCLUSION: Contrary to our hypothesis, infants who were treated with topical benzocaine did not benefit from topical analgesia in terms of crying time. The use of benzocaine for analgesia prior to lingual frenotomy in term infants should therefore be discouraged.

Nosocomial cutaneous abscesses in septic infants.

OBJECTIVE: To retrospectively study the epidemiology of nosocomial cutaneous abscesses in 46 consecutive septic infants. RESULTS: Ten infants had one abscess or more. Surviving infants with abscesses had a longer duration of bacteraemia, which disappeared within 24 hours of drainage. CONCLUSION: Infants with persistent bacteraemia should be examined regularly for the presence of abscesses.

Neonatologists are using much less dexamethasone.

Two historical cohorts (1993-1994 and 2001) of preterm infants ventilated for respiratory distress syndrome were compared. Dexamethasone administration fell from 22% to 6%. Chronic lung disease in survivors rose slightly from 13% to 17%, and mortality fell from 21% to 15% (other causes). The effect of restriction of dexamethasone use on chronic lung disease and mortality remains to be seen.

Effect of ethnicity on mortality of very low birthweight infants in Israel.

BACKGROUND: Multiple demographic, genetic, and environmental factors differ between Muslim and Jewish infants in Israel. OBJECTIVE: To evaluate whether, after adjustment for perinatal factors associated with mortality, excess mortality occurs in very low birthweight (VLBW) Muslim compared with Jewish infants. DESIGN: The Israel National VLBW infant database includes data on 99% of all VLBW births in Israel. The study population comprised 5015 Jewish and 1549 Muslim VLBW infants of more than 23 weeks gestation, born between 1995 and 1999. The Mantel-Haenszel test was used for stratified analysis and logistic regression analysis to assess the effect of ethnic origin on mortality. RESULTS: The death rate was significantly higher among Muslim infants (22.7% v 17.2%; crude odds ratio 1.42; 95% confidence interval 1.24 to 1.63). Excess mortality in Muslims occurred mainly in the 32-33 week (8.0% v 2.8%) and >33 week (14.7% v 4.7%) gestational age groups, and in birthweight groups of 1000-1249 g (17.6% v 9.3%) and 1250-1500 g (9.1% v 3.6%). In VLBW infants without congenital malformations, there was a significantly higher risk of mortality among Muslim infants (odds ratio 1.28; 95% confidence interval 1.04 to 1.57) compared with Jewish infants, after adjustment for gestational age, birth weight, small for gestational age, prenatal care, prenatal steroid treatment, plurality, mode of delivery, and Apgar score. CONCLUSIONS: Excess mortality was present among Muslim VLBW infants without congenital malformations. Perinatal factors associated with increased risk of mortality were more prevalent in the Muslim VLBW population. The pattern of disparities suggests inadequate access to, or utilisation of, effective perinatal technology in the Muslim population in Israel.

A reappraisal of neonatal blood chemistry reference ranges using the Nova M electrodes.

The objective of this study is to establish new reference ranges for whole blood electrolytes, gases, and selected chemistries in normal healthy newborn infants obtained from cord blood and at 2-4 hours of life based on modern analytic techniques. Healthy appropriate-for-gestational age (AGA), term infants were studied. Whole venous cord blood and blood drawn at 2-4 hours of life were analyzed for gases, sodium, potassium, chloride, ionized calcium, ionized magnesium, hemoglobin, and hematocrit. Concentrations for blood glucose and blood urea nitrogen were close to older published concentrations. Na(+), K(+), and Cl(-) were significantly different and had much narrower normal margins. New norms are included for blood gases, lactate, iCa, and iMg. We offer a range of values for often-measured blood chemistries in term, healthy infants, using modern laboratory methods. These values could serve as more up-to-date references compared with older values found in major textbooks of Neonatology.

Double catheter technique for misdirected umbilical vein catheter.

We studied the success rate of the double catheter technique during umbilical vein catheter placement in 42 patients with a misdirected umbilical vein catheter. The misdirected catheter was left in place, and an additional catheter was inserted. X-ray films confirmed that successful placement was achieved in 50% of infants without significant adverse effects.

Prognostic significance of hyperechogenic lesions in the basal ganglia and thalamus in neonates.

Neonatal cranial ultrasonography at times reveals hyperechogenic lesions in the basal ganglia and thalamus. These lesions have been attributed to a wide variety of pathologic states, among them toxoplasmosis, rubella, cytomegalovirus, and herpes simplex (TORCH) infections, chromosomal abnormalities, and asphyxia. The clinical significance in terms of the neurodevelopmental outcome of this radiologic abnormality is unknown. We performed a developmental evaluation on 16 children aged 2 to 6 years in whom neonatal cranial ultrasonography had demonstrated hyperechogenic lesions in the basal ganglia or thalamus and had no other neurodevelopmental risk factors. There was no significant difference between the average Developmental Quotient of the target population and the normal population in regard to developmental status. We conclude that in our population, an isolated finding of hyperechogenic lesions in the basal ganglia is probably not a predictor of poor neurodevelopmental outcome.

A comparison of intakes of breast-fed and bottle-fed infants during the first two days of life.

OBJECTIVE: In the first days of life, breast-fed infants consume minimal amounts of milk; this may be explained by substrate limitation (limited milk output) and/or by self-limitation (through low appetite and/or suck-swallow competency). The spontaneous milk intake of unrestricted formula-fed infants has not been studied to date. We compared the spontaneous formula intake of unrestricted formula-fed infants to that of breast-fed infants over the first 48 hours of life. We hypothesized that 1) spontaneous formula intake of unrestricted infants is much higher than that of breast-fed infants and 2) spontaneous formula intake correlates positively with gestational age or birthweight. METHODS: We studied 43 healthy, term infants. By maternal choice, 15 infants were exclusively breast-fed and 28 were formula-fed ad libitum every four hours. Breast-fed infants were weighed before and one hour after initiation of feeding, and intake was calculated from the difference between the measurements and corrected individually for the infant's normal postnatal decrease in body weight. Bottles offered to formula-fed infants contained 60 cc, and the remainder was carefully measured. Intakes were expressed as cc/kg/d, and weight changes as % of birthweight. Statistical methods included Student's t tests and stepwise regression analysis. RESULTS: Breast feeding on Day I was 9.6 +/- 10.3 (mean +/- SD) vs. 18.5 +/- 9.6 cc/kg/d in formula-fed infants (p=0.011); on Day 2 it was 13.0 +/- 11.3 vs. 42.2 +/- 14.2 cc/kg/d (p<0.001). Breast-fed infants lost significantly more weight on Day 2 (p=0.015). In multiple regression, when the dependent variable was the second-day intake, the significant independent variables were group (higher intake in the formula-fed group), weight loss (the higher the weight loss, the lower the intake), and first-day intake (the higher the first-day intake, the higher the second-day intake). CONCLUSION: Newborn infants offered formula ad libitum every four hours consumed much larger amounts than breast-fed infants fed according to the same schedule. In addition, weight loss was more marked in breast-fed infants on Day 2 of life.

Precision of a new thermometer for rapid rectal temperature measurement in neonates.

The objective of this article is to evaluate the accuracy and reproducibility of a Penguin electronic thermometer compared with a mercury-in-glass thermometer for rectal thermometry in newborns. The mercury-in-glass thermometer is considered the "gold-standard" for rectal thermometry. Unfortunately, accurate measurement with a mercury-in-glass thermometer requires at least 4 minutes. Rectal temperature was obtained in 224 term and near-term infants using a mercury-in-glass and a Penguin thermometers. Paired t-test was used to test the difference between the means, and F-test was used to test the difference between the variances of the two instruments. One hundred and sixty-one of the temperature measurements (72%) taken with the Penguin thermometer were within +/-0.2 degrees C and 208 (93%) within +/-0.5 degrees C from the measurements made with the mercury-in-glass thermometer. The differences in means and in variances were not significantly different between the instruments. The Penguin thermometer is an accurate and reproducible tool for measuring rectal temperature in term and near-term infants compared with the mercury-in-glass thermometer.

Nucleated red blood cells in meconium aspiration syndrome.

OBJECTIVE: To evaluate whether the absolute nucleated red blood cell (RBC) count is higher in infants who had meconium aspiration with respiratory symptoms compared with infants with asymptomatic meconium aspiration and controls. METHODS: We compared the absolute nucleated RBC counts during the first 12 hours of life in three groups of term, vaginally delivered infants, including those who had meconium aspiration with respiratory symptoms (n = 11), asymptomatic meconium aspiration (n = 45), and control healthy infants (n = 32). We excluded infants of women with diabetes in pregnancy; hypertension; alcohol, tobacco, or drug abuse; and those with hemolysis, blood loss, or chromosomal anomalies. RESULTS: There were no significant differences among groups in gestational age; gravidity; parity; maternal analgesia; lymphocyte, platelet, and granulocyte counts; and hematocrit. The median nucleated RBC count was significantly higher in the meconium aspiration group with respiratory symptoms (0.007 x 10(9)/L) than the asymptomatic meconium aspiration group (0.004 x 10(9)/L) or controls (0.003 x 10(9)/L). CONCLUSION: At birth, infants with meconium aspiration syndrome had higher absolute nucleated RBC counts compared with infants with asymptomatic meconium aspiration and normal infants.

Continuous measurement of core body temperature in preterm infants.

We tested a transcutaneous core temperature sensor using a method that relies on the principle of zero heat flow. We tested the hypothesis that transcutaneous and rectal temperatures would track within 0.3 degrees C of each other for >90% of the time. A thermistor was placed between the infant's abdomen or back and the incubator's or radiant warmer's mattress, or within the axilla, attached to the skin with a foam adhesive disk insulator. Thirty preterm infants were either placed on their abdomens or backs in a convective incubator or under a radiant warmer, and continuous transcutaneous and rectal temperatures were measured for 1 hour. There were no significant differences between abdominal and core temperatures or between axillary and core temperatures measured in double-walled convective incubators or in radiant warmers. The rectal-abdominal temperature difference was significantly less than the rectal-axillary difference (p < 0.02) in convective incubators, but not when the infant was placed prone under radiant warmers (p = 0.27). Transcutaneous thermometry is reliable for monitoring core body temperature as indicated by rectal temperature in stable preterm infants in a convective incubator.

Early postnatal dexamethasone treatment and increased incidence of cerebral palsy.

OBJECTIVE: To study the long term neurodevelopmental outcome of children who participated in a randomised, double blind, placebo controlled study of early postnatal dexamethasone treatment for prevention of chronic lung disease. METHODS: The original study compared a three day course of dexamethasone (n = 132) with a saline placebo (n = 116) administered from before 12 hours of age in preterm infants, who were ventilated for respiratory distress syndrome and had received surfactant treatment. Dexamethasone treatment was associated with an increased incidence of hypertension, hyperglycaemia, and gastrointestinal haemorrhage and no reduction in either the incidence or severity of chronic lung disease or mortality. A total of 195 infants survived to discharge and five died later. Follow up data were obtained on 159 of 190 survivors at a mean (SD) age of 53 (18) months. RESULTS: No differences were found between the groups in terms of perinatal or neonatal course, antenatal steroid administration, severity of initial disease, or major neonatal morbidity. Dexamethasone treated children had a significantly higher incidence of cerebral palsy than those receiving placebo (39/80 (49%) v. 12/79 (15%) respectively; odds ratio (OR) 4.62, 95% confidence interval (95% CI) 2.38 to 8.98). The most common form of cerebral palsy was spastic diplegia (incidence 22/80 (28%) v. 5/79 (6%) in dexamethasone and placebo treated infants respectively; OR 4.45, 95% CI 1.95 to 10.15). Developmental delay was significantly more common in the dexamethasone treated group (44/80 (55%)) than in the placebo treated group (23/79 (29%); OR 2. 87, 95% CI 1.53 to 5.38). Dexamethasone treated infants had more periventricular leucomalacia and less intraventricular haemorrhage in the neonatal period than those in the placebo group, although these differences were not statistically significant. Eleven children with cerebral palsy had normal ultrasound scans in the neonatal period; all 11 had received dexamethasone. Logistic regression analysis showed both periventricular leucomalacia and drug assignment to dexamethasone to be highly significant predictors of abnormal neurological outcome. CONCLUSIONS: A three day course of dexamethasone administered shortly after birth in preterm infants with respiratory distress syndrome is associated with a significantly increased incidence of cerebral palsy and developmental delay.

Effect of passive smoking in pregnancy on neonatal nucleated red blood cells.

OBJECTIVE: We evaluated whether the absolute nucleated red blood cell (RBC) count is elevated in term, appropriate for gestational age (AGA) infants born to women exposed to passive smoking in pregnancy. PATIENTS AND METHODS: We compared absolute nucleated RBC counts taken during the first 12 hours of life in 2 groups of term, vaginally delivered infants, 1 group born to mothers who were routinely exposed to tobacco smoke during pregnancy (n = 55) either at home or at the workplace, and the other to mothers who were not routinely exposed to any tobacco smoke (n = 31). We excluded infants of women with conditions known to elevate nucleated RBC counts. RESULTS: There were no differences between groups in birth weight, maternal age, gravidity, parity, maternal analgesia during labor, 1- and 5-minute Apgar scores. Gestational age was minimally higher in the control group (39.6 +/- 1.1 vs 39.2 +/-.8 weeks). The median absolute nucleated RBC count in the passive smoking group was 357 x 10(6)/L (range: 0-5091 x 10(6)/L) versus 237 x 10(6)/L (range: 0-1733 x 10(6)/L) in nonsmoking controls. Stepwise regression analysis that included Apgar scores, gestational age, and the passive smoking status (yes/no) as independent variables showed significant correlation of absolute nucleated RBC count only with the passive smoking status. CONCLUSION: At birth, term AGA infants born to mothers exposed to passive smoking have increased circulating absolute nucleated RBC counts compared with those of controls. We speculate that passive smoking in pregnancy should be avoided, because it may have subtle negative effects on fetal oxygenation.

Mode of delivery and neonatal hematocrit.

The objective of this paper is to test the hypothesis that the 2-h hematocrit (HCT) is lower in infants born by cesarean section (CS) than in infants born vaginally and that the postnatal rise of HCT is lower in infants born by CS than in infants delivered vaginally. We prospectively studied 31 infants delivered by elective CS, 21 infants delivered by CS because of arrest of descent and 30 vaginally delivered (VD) infants. All pregnancies were term, uncomplicated in nonsmoking mothers. Apgar scores were > 7 at 1 and 5 min. In all infants umbilical cord was clamped early. Umbilical vein and 2-h peripheral venous micro-HCT were measured by centrifugation. Cord-blood HCT, 2-h HCT, and rise in HCT were similar in the two CS groups and significantly lower than in the VD group. In multiple regression, gestational age, Apgar score, or the presence or not of labor did not influence cord-blood HCT, 2-h HCT, or the rise in HCT. Infants born by CS have lower HCT than infants born vaginally. Prediction of 2-h HCT from cord-blood HCT must take into account the mode of delivery.

Normoblasts in large for gestational age infants.

Thirty one term large for gestational age (LGA) infants of non-diabetic mothers were compared with 30 appropriate for gestational age controls. Median absolute nucleated red blood cell counts, lymphocyte counts, and packed cell volumes were significantly higher in the LGA infants than the controls. It is possible that LGA babies of non-diabetic mothers are exposed to relative intrauterine hypoxia.

Maturation of thermal capabilities in preterm infants.

Very low-birth-weight infants (VLBW) may initially require environmental temperatures higher than skin temperature. We examined the correlation between gestational age, birth weight, and the time to reach skin-air temperature equilibration (TTE) in VLBW infants. We also examined the effect of antenatal steroids on TTE in infants with birth weight < 1000 g. There is a significant exponential correlation between TTE and birth weight or gestational age (p < 0.05). There was no significant change in TTE in infants who were treated antenatally with steroids, as compared with infants who were not treated. Multiple regression analysis with TTE as the dependent variable and birth weight or gestational age, race, betamethasone treatment, and gender as the independent variables showed a significant correlation between gestational age and TTE (p = 0.04). We conclude that thermal capabilities are exponentially correlated with gestational age or birth weight.

Nucleated red blood cells in healthy infants of women with gestational diabetes.

OBJECTIVE: To evaluate whether absolute nucleated red blood cell (RBC) counts are elevated in large-for-gestational-age (LGA) infants of women with gestational diabetes compared with appropriate-for-gestational-age (AGA) infants of women with or without gestational diabetes. METHODS: We compared absolute nucleated RBC counts during the first 12 hours of life in three groups of term, vaginally delivered infants, LGA infants of women with gestational diabetes (n = 20), AGA infants of women with gestational diabetes (n = 20), and AGA infants of nondiabetic women (n = 30). We excluded infants of women with hypertension, smoking, alcohol or drug abuse, and those with fetal heart rate abnormalities in labor, low Apgar scores, hemolysis, blood loss, or chromosomal anomalies. RESULTS: There were no significant differences among groups in gestational age, gravidity, parity, maternal analgesia, 1- and 5-minute Apgar scores, and lymphocyte counts. Corrected white blood cell counts and hematocrit were significantly higher in LGA infants of women with gestational diabetes than in the other groups. The median nucleated RBC count was significantly higher in LGA infants of women with gestational diabetes (0.56 x 10(9)/L, range 0-1.8 x 10(9)/L) than AGA infants of women with gestational diabetes (0.13 x 10(9)/L, range 0-0.65 x 10(9)/L) and controls (0.0005 x 10(9)/L, range 0-0.6 x 10(9)/L) (P < .001). Multiple regression analysis showed that absolute nucleated RBC count was significantly correlated with birth weight (or macrosomia) and maternal diabetic status (r2 = .25, P < .001 for the multiple regression, contribution of birth weight r2 = .19, and diabetes r2 = .06). CONCLUSION: At birth, term LGA infants born to women with gestational diabetes had higher absolute nucleated RBC counts compared with AGA infants born to women with gestational diabetes and controls.