Continuing evolution of regionalized perinatal care: community hospital neonatal convalescent care.

We describe the convalescent care of 169 back-transported (to community hospitals) and 285 eligible but not back-transported very low birth weight (VLBW) infants. Eligible infants who were not back transported to a level I or II community hospital were transferred to a level II nursery within the Medical University of South Carolina (MUSC) for convalescent care. Study infants were admitted to the neonatal intensive care unit (NICU) at MUSC from July 1985 through June 1989. They were admitted after maternal transport to MUSC for imminent delivery (N = 159), out-born community delivery (N = 55), or in-born MUSC delivery (N = 240). The mean +/- SD birth weight and gestational age and the NICU admission diagnoses for the back-transported and non-back-transported neonates were similar. The mean +/- SD weight of neonates at the time they were back transported was significantly greater than the weight of neonates at the time of intrahospital transfer. In contrast, the discharge weight to home and total days hospitalized were significantly less in the back-transported infants. Five back-transported neonates (3%) and 12 non-back-transported neonates (4%) were readmitted to the NICU. The back-transported infants used more than 3,800 bed days at community hospitals that would otherwise have been spent in the regional center, thus facilitating increased parental and primary physician involvement in their care.

Osteocalcin, skeletal alkaline phosphatase, and bone mineral content in very low birth weight infants: a longitudinal assessment.

Serum osteocalcin (Gla) and skeletal alkaline phosphatase (SAP) concentration both reflect osteoblast activity in the dynamic process of bone formation. To assess the relation in premature infants between change in bone mineral content (BMC) and both Gla and SAP serum concentration, we longitudinally measured BMC via photon absorptiometry and serum Gla and SAP concentration from birth to 16 wk in 20 very low birth weight infants. Serum total calcium, phosphorus, parathyroid hormone, and vitamin D metabolite concentrations were also monitored. All serum values were measured in the 20 mothers at delivery. Cord blood Gla concentrations were significantly (p less than 0.03) greater than maternal levels, and by 1 wk had significantly (p less than 0.001) increased from birth values. Total calcium, parathyroid hormone, phosphorus, and vitamin D concentrations remained in the normal range throughout the study. The increase in serum Gla concentrations, birth to 1 wk, were significantly correlated with the simultaneous increase in 1,25-dihydroxyvitamin D concentrations. The correlation between the change in BMC, however, over the first 4 mo of life and both Gla and SAP serum concentrations failed to reach statistical significance. Finally, a significant (p less than 0.003) negative correlation was measured between serum Gla and SAP concentrations at wk 4, and, although not significant, a consistently negative correlation was measured from 1-16 wk of age.(ABSTRACT TRUNCATED AT 250 WORDS)

How much vitamin D for neonates?

To assess the adequacy of different dosages of neonatal vitamin D, 25-hydroxyvitamin D serum concentrations were longitudinally monitored in 27 low-birth-weight and 25 full-term well infants from birth to 16 weeks after delivery. The infants were randomly assigned to receive either 10 micrograms/d (400 IU/d) or 20 micrograms/d (800 IU/d) of vitamin D or 0.85 or 1.5 micrograms/d of 25-hydroxyvitamin D3. In each infant who received 10 or 20 micrograms/d of vitamin D 25-hydroxyvitamin D, serum concentrations greater than 20 ng/mL were maintained, with some low-birth-weight infants reaching 60-ng/mL concentrations. Similarly, in the low-birth-weight infants receiving 1.5 and 0.85 micrograms/d of 25-hydroxyvitamin D3, serum 25-hydroxyvitamin D levels greater than 12 ng/mL were maintained. In the full-term infants who received 1.5 micrograms/d of 25-hydroxyvitamin D3, serum 25-hydroxyvitamin D concentrations of greater than 12 ng/mL were maintained, but in those who received 0.85 micrograms/d, serum 25-hydroxyvitamin D concentrations of 10 ng/mL could not be maintained. These vitamin D status data document that 10 micrograms (400 IU) of vitamin D represents a sufficient daily intake for both premature and full-term well infants. These data also indicate that while as little as 0.85 micrograms/d of 25-hydroxyvitamin D3 may facilitate vitamin D sufficiency in low-birth-weight neonates, it does not do so in full-term infants.

Bacterial contamination of human milk: container type and method of expression.

Common questions from nursing women include: is the bacterial contamination of expressed milk different if collected manually versus mechanically and is there a large increase in bacterial contamination if the milk is collected into clean versus sterile containers. Similarly, there are mixed reports, and secondarily confusion, among lactating women regarding the benefit of discarding the initial portion of a milk expression to limit bacterial contamination with skin flora. To answer these concerns, we have measured the number of colony-forming units (CFU)/milliliter in expressed milk from 16 women. The experimental design, used in a randomized fashion with each woman, employed both sterile and clean containers for collection and both the manual and mechanical techniques for milk expression. The number of milk specimens containing greater than 10(4) CFU/ml was not different between those collected in clean versus sterile containers or between those collected with a manual versus a mechanical technique. Finally, the initial milk expressed did not have a significantly greater amount of bacterial contamination than the milk collected later in the milk expression.

Longitudinal changes in the bone mineral content of term and premature infants.

With the use of photon absorptiometry, bone mineralization was measured at birth and 8 and 16 weeks after delivery in 12 very-low-birth-weight premature (mean +/- SD gestational age, 31 +/- 1.5 weeks) infants who required minimal medical support. Simultaneously, 19 healthy term infants were studied. Throughout the study, each neonate received modified 84-kJ/30 mL formula containing no added calciferol. The recommended daily allowance (400 IU) of calciferol was given to each infant as an oral supplement. Serum 25-hydroxyvitamin D, calcium, phosphorus, and parathyroid hormone concentrations were monitored biweekly and were normal. Bone mineral content and bone width significantly differed at birth between the term and premature infants. However, by 16 weeks after delivery, the premature infants had exceeded the bone mineral status of the term infants at birth, and their bone mineral content was not significantly lower than that of the term infants. These data indicate improved bone mineralization as compared with previously reported data from very-low-birth-weight neonates.

Group-specific component in neonatal breast secretion: relationship to the cellular content.

Group-specific component (Gc) and total albumin concentrations in the breast secretions from 20 full-term infants were measured. The Gc concentrations as well as the albumin concentrations correlated significantly (p less than 0.02) with the total cell count and the absolute concentration of each white blood cell type in the breast fluid. The ratio of albumin in neonatal breast secretion to that in neonatal serum was similar to the comparable ratio for Gc. Since albumin and Gc are of similar molecular size, these observations suggest leakage of these two proteins from serum to breast secretion and a possible chemotactic relationship between these proteins and the mononuclear cells in neonatal milk.

Newborn lymphocyte subpopulations: the influence of labor.

Cord blood mononuclear cell subsets were enumerated in 31 neonates delivered after maternal labor, in 25 neonates delivered by cesarean section without preceding labor, and in 60 healthy adults. In neonates born with and without preceding labor percentages of CD3 cells were lower than those in adults (63% and 60% as opposed to 83% in adults). However, the absolute numbers of CD3 cells were significantly greater in newborn infants delivered without preceding labor (3.287 +/- 1.451 cells per microliter) than in both neonates born after labor (2.660 +/- 800 cells per microliter) and in adults (2.189 +/- 807 cells per microliter). The increase in CD3 cells in infants delivered without preceding labor reflects increased numbers of CD4-positive cells. This increase in the absolute number of T lymphocytes and CD4 (helper) lymphocytes was significant (p less than 0.02). These data indicate that labor-related stress significantly decreases the total number of neonatal T lymphocytes and the CD4 (helper) T-cell subpopulation in cord blood.

Correlation of bone mineralization in the radius and humerus of well premature neonates over the first 4 months of life.

To determine how well mineralization correlates in the radius and humerus of neonates, we have measured with photon absorptiometry the bone mineral content (BMC) and bone width (BW) in the humerus and radius of well premature neonates and in the radius alone of well term neonates at birth, 8 and 16 weeks of age. These data allow (1) the correlation of bone mineralization in the humerus and radius at birth and over the first 4 months of life and (2) the correlation between bone mineralization in the radius or humerus at birth and that measured at 8 and 16 weeks in the same bone site. The BMC of the radius was significantly (P less than 0.02) correlated with the BMC of the humerus at birth, 8 and 16 weeks, but the BW of the radius was significantly correlated with the BW of the humerus only at 16 weeks. On the other hand, the BMC of the radius at birth in both term and premature neonates failed to correlate significantly (P = ns) with the BMC of the radius at 8 or 16 weeks. In the humerus, the BMC at birth was significantly (P less than 0.001) correlated with that measured at 8 but not at 16 weeks. These data indicate that the humerus and radius increase in mineral content at a similar rate over the first 4 months of life but that one cannot accurately predict from the BMC at birth what the bone mineral content will be at 8 and 16 weeks of age.

Cord blood amino acid concentrations from neonates of 23-41 weeks gestational age.

Amino acid concentrations were measured in the cord blood serum from neonates following 23-41 weeks gestation. These values were then correlated with the gestational age of the newborns. A significant (p less than 0.05) correlation was observed with the concentrations of six amino acids, and five of these correlations were negative. The significance of these normative data are discussed and compared with currently available cord blood aminogram data.

The immunologic composition of neonatal milk: cellular components.

The cellular content of neonatal mammary gland secretions from 12 full-term infants less than 2 weeks postdelivery was studied. The predominant cell types observed were lymphocytes and macrophages with greater than 90% viability in each. The concentration of lymphocytes was significantly (P less than 0.001) correlated with the concentration of macrophages. The immunoglobulin content of this fluid was predominantly IgG with minimal concentrations of IgA, and no IgM detected. These data suggest both the presence of regulatory mechanisms for the cellular composition of neonatal breast secretions and that neonatal milk may bear a significant connection with the developing mucosal immune system.

Newborn hospitalization: a closer look.

To assess the safety of moderately early hospital discharge for normal newborn infants (mean +/- SD, 31 +/- 5 hours after delivery), we compared the incidence of hospital readmission within 6 weeks of birth with the incidence of readmission among a similar cohort of infants with extended hospitalization (mean +/- SD, 92 +/- 44 hours) as a result of maternal illness. The hospital charts for all infants admitted to the well-baby nursery between January 1 and December 31, 1985, were reviewed. Fifty-two (3.0%) of the 1714 infants who were discharged moderately early and 17 (2.7%) of the 622 infants who had an extended hospitalization were readmitted to the hospital by age 6 weeks (P = NS). Maternal age, financial status, and race each failed to predict infant readmission. Only four of the 52 readmission diagnoses among infants discharged moderately early could potentially have been identified (not prevented) before discharge with an extended newborn hospitalization. These data indicate that moderately early neonatal hospital discharge does not result in an increased incidence of rehospitalization within the first 6 weeks of life.