Professional liability in a neonatal intensive care unit: a review of 20 years' experience.

OBJECTIVE: To examine neonatal intensive care unit (NICU) malpractice claims and identify common characteristics likely to result in malpractice. STUDY DESIGN: A retrospective study (1972 to 1992) at a tertiary care children's hospital examining malpractice claims involving NICU infants. RESULTS: A total of 31 cases of malpractice out of 9367 NICU admissions (incidence 0.33%) were found. Although not statistically significant, the incidence of legal action increased with NICU growth from 0.19% (1972 to 1974) to 0.39% (1980 to 1992). Infants who were significantly over-represented in malpractice cases compared with the general NICU population included those who were full-term, white, privately insured, and those with neurologic conditions. Families' motives for legal action included (1) treatment error/delay (48%), (2) missed/delayed diagnosis (16%), (3) equipment malfunction/misuse (6%), and (4) general improper care (30%). CONCLUSION: Based on this research, three factors may be associated with increased risk of malpractice in the NICU: (1) increased unit growth, (2) parental perceptions of negligence, and (3) full-term infants with diagnoses associated with neurologic conditions.

Neonatal autopsies: a 10-year experience.

OBJECTIVES: To identify trends in neonatal autopsy rates at a tertiary care hospital during the last decade, to determine the concordance between antemortem and post-mortem diagnoses, and to describe patient characteristics that influenced diagnostic yield on autopsy. DESIGN: Retrospective review of medical records. SETTING: Tertiary care children's hospital. PATIENTS: All neonatal deaths between January 1, 1984, and December 31, 1993. MAIN OUTCOME MEASURES: For those with autopsies, data included length of stay, diagnostic imaging studies, antemortem diagnoses, and autopsy findings. Autopsy diagnoses were compared with antemortem findings and classified according to concordance. RESULTS: Of 487 neonatal deaths, autopsies were performed in 296 (61%). The autopsy rate declined significantly during 10 years from 71.2% (1984-1988) to 47.7% (1989-1993). New diagnoses were made at autopsy in 44% of cases. Major discordancies were identified in 35 infants (12%); minor discordancies in 95 (32%). Autopsies were more likely to reveal new diagnoses in infants born at 28 to 36 weeks' gestation and in those whose mothers had no prenatal care. Major findings at autopsy were more likely in infants whose mothers had no prenatal care and in infants who died within 6 hours of birth. There was no relationship between new findings at autopsy and age, length of hospital stay, or antemortem imaging studies. CONCLUSIONS: This study reveals a significant decline in neonatal autopsies during a 10-year period. This study also demonstrates that neonatal autopsy continues to provide clinically significant data and remains a valuable tool in perinatal medicine.

Autopsies in children: are they still useful?

BACKGROUND: Autopsy has traditionally been the criterion for determining cause of death and has played a major role in medical education and quality control. With increasing use of bedside technology, however, autopsy rates have steadily declined. OBJECTIVE: To identify (1) trends in pediatric autopsy rates during the past decade, (2) concordance between antemortem and postmortem diagnoses, and (3) patient characteristics influencing autopsy rates or diagnostic yield. METHODS: All pediatric deaths between January 1, 1984, and December 31, 1993, were retrospectively reviewed. Data collection included demographics for all patients, and length of stay, diagnostic imaging studies, antemortem diagnoses, and autopsy findings for patients with autopsies. Autopsy diagnoses were compared with antemortem findings and classified according to their concordance. RESULTS: Of 297 pediatric deaths, autopsies were performed on 107 patients (36%). Autopsy rates did not change significantly during the study period. Autopsies were not associated with patient gender, race, or insurance status, but increased significantly with age. Autopsies were performed in 26% of infants 12 months or younger, 60% of children between 13 to 60 months of age, and 100% of children 61 months or older (chi2; P <.001). In 34% of cases, new diagnoses were made at autopsy, including 7 cases where new findings, if known before death, would likely have resulted in a change in treatment or improved survival. There was no relationship between new findings at autopsy and age, length of hospital stay, or antemortem imaging studies. CONCLUSIONS: Autopsy can provide additional information in more than one third of pediatric deaths. Pediatric autopsy continues to provide clinically significant data and remains a valuable tool in modern pediatric practice.

Getting enough: mothers' concerns about breastfeeding a preterm infant after discharge.

OBJECTIVE: To describe maternal concerns about breastfeeding a preterm infant in the postdischarge period and to delineate the strategies mothers used in managing these concerns. DESIGN: Naturalistic inquiry was used. SETTING: A semistructured interview was conducted with the mother in the home 1 month after discharge of the infant. PARTICIPANTS: Twenty mothers of preterm infants; the infants had been in a level 3 hospital nursery, and the mothers had received individualized breastfeeding support services in the hospital. MAIN OUTCOME MEASURES: Three categories of maternal concerns emerged from the data: adequate milk consumption by infants; milk composition; and problems with the mechanics of breastfeeding a preterm infant. Mothers identified strategies for these concerns. RESULTS: The mothers' main concern was whether infants consumed an adequate volume of milk by breastfeeding alone. Strategies for managing concerns about getting enough included using supplemental and complemental feeding, using ongoing cues to tell that the infant is getting enough, and persevering with breastfeeding. CONCLUSIONS: Mothers of preterm infants have unique concerns about breastfeeding in the postdischarge period and need individualized interventions.

A new scale for in-home test-weighing for mothers of preterm and high risk infants.

The purposes of this research were to describe the accuracy of test-weighing with the BabyWeigh, a new infant scale suitable for use in the home, and to determine whether mothers and investigators could estimate intake accurately during breastfeeding sessions, using clinical cues that are recommended for this purpose. Within five days of projected NICU discharge, 30 preterm and/or high risk infants and their mothers were studied during a single breastfeeding session. A member of the research team performed test-weights with the Smart Model 20 infant scale, and mothers performed test-weights with the BabyWeigh scale. The mothers and investigators each estimated volume of intake for the breastfeeding session using clinical cues. Mothers and investigators were blind to each others' test-weights and clinical estimates. Results revealed that the BabyWeigh scale provided an accurate estimate of intake during breastfeeding across a large range of infant weights and intake volumes. In contrast, investigator and maternal estimates of intake were not sufficiently accurate.

Intrathrombic urokinase reverses neonatal renal artery thrombosis.

A term infant with aortic and renal artery thrombosis is described, in whom the right kidney experienced complete ischemia for 5 days. A continuous intrathrombic urokinase infusion induced complete clot lysis and reperfusion of the right kidney. Follow-up studies of renal function and renal growth have been normal. This is the first report to describe complete pharmacological salvage of a neonatal kidney after prolonged warm ischemia. This case underscores both the ability of the neonatal kidney to recover from prolonged ischemia and the need to effect thrombolysis before irreversible renal injury occurs. The intrathrombic use of fibrinolytic agents in similarly affected infants warrants consideration and further study.

Breastfeeding support services in the neonatal intensive-care unit.

OBJECTIVE: To describe a model for providing breastfeeding support in the neonatal intensive-care unit (NICU). DESIGN: Naturalistic, participant observation. SETTING: Suburban Level III NICU. PATIENTS: One hundred thirty-two mother-infant pairs over 1 year. Infants were hospitalized in the NICU, and mothers had initiated lactation efforts. INTERVENTIONS: Investigators provided breastfeeding interventions for the mother-infant pairs, based on identified problems, the research literature, or both. MAIN OUTCOME MEASURES: Percentage of mothers who were breastfeeding at the time of discharge from the NICU. RESULT: Interventions were classified into five categories: expression and collection of mothers' milk, gavage feeding of expressed mothers' milk, in-hospital breastfeeding sessions, postdischarge breastfeeding management, and additional consultation. CONCLUSIONS: This model was effective in preventing breastfeeding failure for this population. The model can provide the basis for NICU breastfeeding standards of care, protocols, and chart records, or for reimbursement purposes. The model also provides a framework for studying a specific category or breastfeeding intervention.

Concurrent validity of a new instrument for measuring nutritive sucking in preterm infants.

The purpose of this study was to examine the concurrent validity of the Whitney strain gage for the measurement of nutritive sucking in preterm infants. Ten preterm infants were studied continuously during at least one entire bottle feeding per week, from admission into the study until discharge from the nursery. Sucking was measured simultaneously by an adapted nipple and the Whitney gage. The two instruments were compared on the following measures: number of sucking bursts, number of sucks per burst, and duration of bursts and pauses between bursts. Total percent agreement for the occurrence of a sucking burst was 99.3% (K = .99). Sucks per burst varied from 2 to 113, with 89.3% of the pairs of sucking bursts differing by < or = 1 suck per burst. The mean absolute difference between the two instruments for the duration of sucking bursts and pauses was .64 s and .72 s, respectively. These results demonstrate the concurrent validity of the Whitney gage for measurement of sucking events in preterm infants.

Pharmacokinetics of lorazepam in critically ill neonates with seizures.

Pharmacokinetic data were evaluated in 10 term neonates with seizures after intravenous administration of lorazepam, 0.05 mg/kg or 0.1 mg/kg. All seizure activity ceased, with no adverse effects. Pharmacokinetic data revealed a decreased volume of distribution and clearance, and a prolonged half-life in comparison with data from older children and adults. These findings are consistent with physiologic differences in the neonate.

Colonic strictures following successful medical management of necrotizing enterocolitis: a prospective study evaluating early gastrointestinal contrast studies.

This is a prospective study of 50 patients with neonatal necrotizing enterocolitis (NEC) treated successfully by medical means. They were all screened with an upper gastrointestinal (GI) contrast study after 14 days of healing and prior to establishment of feeding. Thirty-six patients (72%) with normal upper GI examinations responded well to a graduated increase in feeding. Another 5 (10%) with questionable areas on their upper GI examination had a normal follow-up contrast enema. Feeding was successfully established in this group of infants also. The remaining 9 patients (18%) had demonstrable strictures in both contrast studies. After elective resection of strictures with restoration of intestinal continuity, they were also fed successfully. No delayed strictures were seen in any of the patients. We propose that this method of evaluation is safe, efficient and reliable in the diagnosis of strictures that develop in patients recovering from NEC.

Home death and hospital follow-up of the dying infant.

As technology and medical care have improved, increasing numbers of critically ill neonatal patients are surviving the immediate neonatal period. The hectic environment of the neonatal intensive care unit often makes it difficult for personnel to attend adequately to the needs of the dying infant and his family. Accordingly, the option of home death for such infants has been offered in our neonatal intensive care unit. Experience is described for six infants who were managed in this manner.

The accuracy of test weighing for preterm infants.

A series of recent studies has suggested that preterm infants are capable of breast feeding at weights less than 1,500 g. However, estimating intake during breast feeding for these small infants is important for safe clinical practice and valid research. The purpose of this study was to compare the accuracy of test weighing as an estimate of intake for preterm infants using two types of scales: a mechanical scale (Toledo) commonly used in many special care nurseries, and a new electronic scale (SMART; Olympic Medical). Fifty clinically stable preterm infants, weighing between 1,088 and 2,440 g (mean = 1,599 g), who were clothed identically for all weights and feedings, were studied. Two experienced neonatal nurses (RN-1 and RN-2) collected the data. Before feeding, each infant was weighed once on each scale by each nurse; the order of nurse and scale was assigned randomly. Then, RN-1 administered a prescribed volume of feeding. After feeding, RN-2 weighed each infant twice on each scale; the order of scale was assigned randomly. RN-1 was blind to postfeed weights, and RN-2 was blind to actual volume of intake. Results indicated that differences between the actual and estimated volumes of intake were smaller for the electronic than for the mechanical scale on all measures. These findings suggest that test weighing with an electronic scale provides an accurate estimate of intake for preterm infants, and support the use of this instrument in clinical practice and research.

Nasal glioma. Presenting as neonatal respiratory distress. Definition of the tumor mass by MRI.

Nasal gliomas are benign congenital midline tumors with the potential for intracranial extension. They are most commonly seen in neonates and children but rarely in adults. The treatment of choice is surgical excision. Inadequate primary excision results in a 4 to 10 percent recurrence. Hence, a thorough preoperative evaluation is essential to delineate the exact site and extension of the tumor and to plan the appropriate surgical approach. Computerized tomographic (CT) scans are useful in visualizing bony defects, but are not well suited for soft tissue imaging. Magnetic resonance imaging (MRI) offers superior soft tissue contrast, without ionizing radiation. This is a report of a neonate with unexplained early respiratory distress. On day 5, a soft nasal mass became apparent. CT scans were inconclusive, so MRI scan was used to demonstrate intracranial extension. MRI is superior for imaging brain tissue, so it should be used preferentially to delineate intracranial extension and to help guide the surgical approach.

Grief reaction to sudden unexpected cardiorespiratory arrest in a normal newborn nursery.

The authors report two cases of sudden unexpected cardiorespiratory arrest occurring in a normal newborn nursery. They discuss the impact on the families and hospital personnel. The nursing and medical staff demonstrated many of the reactions experienced by families of sudden infant death syndrome (SIDS) victims, including shock, anger, guilt, disbelief, fear, and doubt. The manner in which hospital personnel were supported and counseled is discussed. Specific clinical implications of these cases, including the need to provide for appropriate monitoring and resuscitation in normal newborn nurseries, are presented.

Lorazepam in the treatment of refractory neonatal seizures. A pilot study.

Seven neonatal patients with severe seizures unresponsive to conventional anticonvulsant therapy were treated with lorazepam. Immediate cessation of seizure activity occurred in all patients within five minutes. Although seizures recurred in two infants eight hours later, frequency and severity diminished. There were no apparent significant side effects attributed to the medication.

Distal ileostomy drip feedings in neonates with short bowel syndrome.

When a newborn infant presents with high intestinal atresia, the proximal segment of the bowel is usually grossly distended and atonic. The anastomosis of this segment to the smaller and unused distal segment will usually result in little or no propulsion of contents distally. Many techniques have been employed to correct this problem. A common surgical approach is immediate end-to-end anastomosis, followed by parenteral alimentation until return of normal function. This can take many weeks, and requires special attention to fluid loss and complications associated with parenteral alimentation. In this paper we report two infants in whom we utilized a new technique to circumvent these problems. The technique involves continuous drip ileostomy feedings through the distal ileostomy, while basic nutritional needs are being met parenterally. In addition, the secretions from the proximal stoma are collected and infused with the elemental feeding. The distal bowel, now being fully utilized, is stimulated to accommodate, and when the two ends are joined at a second operation, nearly normal anatomical bowel is present.

The role of RBC transfusion in the premature infant.

Fifty-six premature infants with a mean gestational age at birth of 30 weeks were randomly assigned to a transfusion group, for whom the hemoglobin level was kept above 10.0 g/dL, and a nontransfusion group, who were transfused only for specific clinical indications. The groups were followed up longitudinally with weekly determinations of reticulocyte count, the partial pressure of oxygen at which 50% of hemoglobin is saturated, and hemoglobin F percentage, as well as weight gain, length of stay, hospital cost, and frequency and severity of apnea. At birth, there was no significant difference in birth weight, gestational age, and hemoglobin level between the two groups. At discharge, laboratory differences were noted between the two groups, but there was no clinical difference. We found no clinical advantage to the use of "booster" RBC transfusions in growing premature infants.

Blood component transfusion in the intensive care nursery. Indications and special problems.

Increasingly, transfusions of component blood products are used in the setting of the neonatal intensive care unit. There is a need to analyze the indications and potential complications of this therapy critically. We review here the problems primarily unique to the neonatal population and suggest an approach to the transfusion requirements of this group. Specifically, we discuss the rationale, indications and complications of red cell, granulocyte, and platelet transfusions in these patients. Discussion of exchange transfusion and the particular blood banking requirements of these patients will be reviewed in subsequent articles.