[The very small premature infant. Ethical problems from a neonatology viewpoint]. / Das sehr kleine Frühgeborene. Ethische Fragen aus neonatologischer Sicht.

The opening text of the conference provides a summary of the definitions, the probabilities, the mortality rate, the postnatal risks and the perspectives for life of very small newborn babies. The best indicator for the later development of the child is the length of gestation and the birth weight. The care of the parents themselves is very important, as they are going through a very difficult period of changing emotions, anxiety, guilt, joy and grief. The further development of the child can only be forecast with probabilities and not with certainties; therefore, every decision for or against the life of a prematurely newborn baby can be either correct or incorrect. The place for taking this kind of decision is within the team caring for the baby. The difficult process of decision-making and its responsibility cannot be handed over to the parents. The final responsibility lies in the hands of the physician.

[Prevalence of drugs in meconium]. / Prävalenz von Drogen im Mekonium.

BACKGROUND: The number of newborn infants with symptoms suggesting drug withdrawal is increasing. As only part of prenatally exposed infants show typical drug withdrawal, and drug-use reported by addicted mothers is often unreliable the prevalence of neonates that were exposed to illicit drugs before birth is unknown. The purpose of this study was to evaluate prospectively the prevalence of drugs in meconium and to define risk factors for intrauterine drug exposure. METHODS: During a period of 4 months meconium was collected twice in 420 nonselected newborn infants. Meconium was analysed with a modified test developed for toxicology screening in urine. Information on pre- and postnatal risk factors including drug-use during pregnancy was obtained. RESULTS: Among 415 mothers four reported illicit drug use and ten licit drug use during late pregnancy. In all these infants meconium drug test was positive. After exclusion of these infants and of five second twins 401 infants with negative drug history remained. 45 of them (11%) had one or two drugs in the meconium: opiate 17x, amphetamine 16x, barbiturate 15x, benzodiazepine 3x, cannabinoid 2x, cocaine 1x (in 9 infants two substances were detected). None was positive for LSD or phencyclidine. The infants with positive drug tests had the following risks compared to those with negative tests: prematurity (odds ratio 2.3, 95% confidence interval 1.3-4.3). Microcephaly or macrocephaly (2.0:1.01-4.1), Apgar-Score below 5 at 1 min (2.4:1.5-5.4), Apgar score below 7 at 10 min (4.0: 1.6-9.9), mother academic (2.8:1.2-6.2). CONCLUSIONS: Newborn infants may have been exposed to illicit drugs in utero even if their mothers deny drug use and even if they do not show withdrawal symptoms. Prematurely born infants and infants with problems in postnatal adaptation have an increased risk of having been exposed to drugs.

[Detection of drugs in meconium]. / Nachweis von Drogen im Mekonium.

BACKGROUND: The number of newborn infants exposed to drugs in utero is on the increase in many European countries. As drug use reported by addicted pregnant women is unreliable there is a need for an accurate test to determine the drugs to which an infant has been exposed in utero. The purpose of this study was to evaluate the reliability of toxicology testing in meconium compared with traditional urine testing. METHODS: From twenty newborn infants born to drug-dependent mothers, meconium and urine were collected as soon as possible after birth and tested for drugs with the same radioimmunoassay. Five neonates were premature (Gestational weeks less than 37), six were small and three microcephalic for gestational age. RESULTS: Meconium was positive for drugs in 19 infants (95%) (Methadone 9, Morphine 9, Cocaine 6, Cannabis 4). Urine testing revealed the presence of drugs in 13 babies (65%) (Methadone 9, Morphine 6, Cocaine 4, Cannabis 1, Barbiturates 1). Five infants did not have any drug withdrawal, five had mild and ten severe withdrawal symptoms necessitating treatment with chlorpromazine and in four instances additional pethidine. CONCLUSIONS: Meconium is not only easier to collect but also at least as reliable as urine for drug detection in neonates.

A European multicenter randomized controlled trial of single dose surfactant therapy for idiopathic respiratory distress syndrome.

We performed a multicenter prospective randomized controlled trial to determine the efficacy and safety of the surfactant preparation, Survanta (Abbott Laboratories, Chicago, USA), for 750-1750 g infants with idiopathic respiratory distress syndrome, (IRDS) receiving assisted ventilation with 40% or more oxygen. One hundred and six eligible infants from the eight participating centers were randomly assigned between March 1986 and June 1987 to receive either surfactant (100 mg phospholipid/kg, 4 ml/kg) or air (4 ml/kg) administered into the trachea within 8 h of birth (median time of treatment 6.2 h, range 3.2-9.1 h). The study was stopped before enrollment was completed at the request of the United States Food and Drug Administration when significant differences were observed in incidence of periventricular-intraventricular hemorrhage (PIH), between the surfactant treated and control infants. Surfactant treated infants had larger average increases in the arterial-alveolar oxygen ratio, (a/A ratio) (P less than 0.0001), and larger average decreases in FiO2 (P less than 0.0001) and mean airway pressure, (MAP) (P less than 0.017) than controls over the 48 h following treatment. The magnitude of the differences between the surfactant and control groups were 0.19 (SE = 0.03) for a/A ratio, -0.28 (SE = 0.04) for FiO2 and -1.7 cm H2O (SE = 0.70) for MAP. The clinical status on days 7 and 28 after treatment was classified using four predefined ordered categories: (1) no respiratory support; (2) supplemental O2 with or without continuous positive airway pressure (CPAP); (3) intermittent mandatory ventilation; and (4) death. There were no statistically significant differences in the status categories on days 7 or 28 between surfactant and control infants.(ABSTRACT TRUNCATED AT 250 WORDS)

[Listeriosis in the newborn infant: improved prognosis due to early detection]. / Listeriose beim Neugeborenen: bessere Prognose dank Früherkennung.

Perinatal clinical data were collected retrospectively from 35 newborn infants infected with Listeria monocytogenes and compared with the subsequent outcome. The average annual incidence of neonatal listeriosis in the Canton of Zurich (Switzerland) between 1983 and 1987 was 0.33 per 1000, which is more than twice that during the preceding 10 years. This increase paralleled a similar outbreak in the French part of Switzerland, where contaminated soft cheese was found to be the source. Three infants were probably cross-infected in the delivery room. Antenatal symptoms included fever in the mother, greenstained amniotic fluid, pathological cardiotocogram, premature contractions and disappearance of fetal movements. After birth the infants showed respiratory distress, fever or hypothermia, exanthema or neurological abnormalities. A gram stain of the gastric content was highly accurate in predicting listeria infection (92% sensitivity, 90% specificity). Five infants died, all within 24 h of birth; seven infants survived with and 23 without, sequelae. Factors associated with fatal outcome were a short gestational age, a low birth weight and a long interval between onset of symptoms and delivery or first dose of an appropriate antibiotic. Cephalosporins were not effective in four infants and therefore should not be given alone to pregnant women and newborn infants as long as Listeria monocytogenes infection is not excluded.

[Clinical assessment of a new glucose reflectance meter (Glucoscot II) for the detection of neonatal hypoglycemias]. / Klinische Erprobung eines neuen Glukosereflektometers (Glucoscot II) zur Erfassung neonataler Hypoglykämien.

Glucoscot II, a new glucose reflectance meter and the corresponding test strip "Glucopat" were evaluated for their accuracy in the detection of neonatal hypoglycemia. In 100 neonatal blood samples of 44 neonates glucose was estimated with the reflectance meter and the results were compared with those from a reference method (Beckman-Glucose-Analyser). Hypoglycemia was defined as blood glucose of less than 2.2 mmol/l (40 mg/dl). The correlation between the values obtained by the test strip and the reference values was high (= 0.95). Test sensitivity was 100%, specificity 99% and the predictive value for hypoglycemia was 94%. The incidence of a blood sugar less than 2.2 mmol/l in our study population was 15%. Thirteen percent of glucose values determined with the reflectance meter deviated from the reference value by more then 20%. If our data can be confirmed by others we conclude that the Glucoscot II/Glucopat-system can be recommended as screening-test for hypoglycemia in neonates.

[Assessment of neonatal hypoglycemia with 2 test strip methods]. / Erfassung von Neugeborenenhypoglykämien mit zwei verschiedenen Teststreifenmethoden.

We evaluated two glucose test strips for their accuracy in detecting hypoglycemia in newborn infants. Reflotest-Hypoglycemia and Haemo-Glucotest and the reflectance meter technique Reflomat I and Reflolux II respectively were used for screening blood sugar values, and compared with laboratory glucose determination using an automatic analyzer (glucose oxidase method). In 134 neonatal blood samples of 56 newborn infants glucose was quantified with the three methods. Hypoglycemia was defined as blood glucose of less than 2.2 mmol/l (less than 40 mg/dl). Test sensitivity was 71%, specificity 97% for Reflomat I, 88% and 82% for Reflolux II, respectively. Analysing the falsely normoglycemic values measured by Reflomat I, no true blood sugar value below 2 mmol/l (less than 36 mg/dl) was found, and no value below 1.2 mmol/l (less than 22 mg/dl) measured by Reflolux II. Defining hypoglycemia as a blood glucose value of less than 2 mmol/l (less than 36 mg/dl) the sensitivity for Reflomat I would be 100%; therefore, significant hyoglycemia should not be missed with this test. Both tests give some false-positives; 3 of 100 Reflomat I and 18 of 100 Reflolux II readings were falsely below 2.2 mmol/l (less than 40 mg/dl). From these data we conclude that Reflomat I is an accurate screening-test for hypoglycemia in neonates; while the use of Reflolux II would cause too much unnecessary treatment.

[Sonographic screening for hip dysplasia in newborn infants]. / Sonographisches Hüftdysplasie-Screening beim Neugeborenen.

The hips of 335 unselected newborn children have been examined sonographically to evaluate the general use of ultrasound in screening programs for early recognition of hip dysplasia. Ultrasound findings indicating the need for treatment in 4% of the children were surprisingly high compared to earlier data on the frequency of hip dysplasia from purely clinical studies. However, this is to be seen in relation to the still significantly late diagnoses of dysplasias or even luxations in later childhood, adolescence and adults. Because of the importance of early recognition of hip dysplasia for treatment and outcome, it can be concluded even from the limited data available that ultrasound examination of the hips should be included in health surveillance programs of newborns.

[Meconium peritonitis: description of 3 cases with abnormal prenatal ultrasound findings]. / Mekoniumperitonitis: Beschreibung von 3 Fällen mit abnormen pränatalen Ultraschallbefunden.

We describe three children with surgically confirmed meconium peritonitis. All had abnormal prenatal ultrasonographic examinations. The first child showed multiple cysts, the second had hydrops fetalis, and the third had dilated bowel loops. A polyhydramnion was common to all three cases. Of the two children who died, one had cystic fibrosis. It is remarkable that the ultrasonographic findings were different in the three children.

[Effectiveness of low- and high-dose caffeine on idiopathic bradycardia and hypoxemia in premature infants]. / Wirksamkeit von niedrig und hoch dosiertem Coffein auf idiopathische Bradykardien und Hypoxämien bei Frühgeborenen.

The efficacy of low and high dose caffeine on idiopathic bradycardia and hypoxaemia was tested in premature infants. Among 41 infants admitted to the study 21 fulfilled the criterion for treatment, e.g. greater than 3 bradycardia or greater than 3 hypoxaemia during 6 h, and received a low dose of caffeine citrate (loading dose 10 mg/kg, maintenance dose 5 mg/kg/24 h) resulting in serum concentrations of 42 +/- 19 mumol/l (M +/- SD). Four infants had to be excluded later because a possible cause for the increased frequency of bradycardia and hypoxaemia was found. Ten infants met the treatment criterion once more and got a double dose of caffeine resulting in serum concentrations of 90 +/- 35 mumol/l. The efficacy of caffeine was evaluated by comparing for each infant the 12-h period preceding the treatment with three 12-h periods during treatment. Low dose caffeine reduced significantly the frequency of bradycardia (less than 0.01), but not the frequency of hypoxaemia. In those infants with insufficient response, who consequently got high dose caffeine, the frequency of bradycardia decreased significantly (p less than 0.01), whereas the frequency of hypoxaemia did not. These results have to be confirmed in a randomized placebo controlled trial.

Intravenous administration of human IgG to newborn infants: changes in serum antibody levels to group B streptococci.

A human IgG preparation was given intravenously to 36 newborn infants admitted to the neonatal intensive care unit because of suspected septicaemia. IgG was given as a single dose of 0.4 g/kg body weight. Patient serum was obtained immediately before and 30 min after terminating the infusion. Blood was also withdrawn 2 days after giving the IgG in eight of the infants. The sera were tested by radioimmunoassay for IgG antibody levels to surface antigens of group B streptococci (GBS) types Ia, Ib, II and III and to R-protein. The mean increases in anti-type Ia, Ib, II, III and R-protein antibodies 30 min after the end of infusion were 81%, 73%, 49%, 60% and 69% of the preinfusion levels, respectively. This was followed by a rapid decrease during the following 2 days to 25%-32% of the initial increases. Based on the above findings, a controlled trial of passive immunisation in the management of neonatal GBS septicaemia seems justified. The rapid decline in antibody levels would necessitate a second infusion 24 h after the initial immunoglobulin administration if the suspicion of septicaemia persists.

EEG spectral power and coherence analysis in healthy full-term neonates.

Continuous, bipolar EEG recording was performed in nineteen healthy full-terms during quiet sleep (Q), REM sleep (R) and wakefulness (W). Spectral power was calculated for the bilateral fronto-central (FC), centro-parietal (CP), parieto-occipital (PO) and temporal (TT) derivations. Coherence was determined for the interhemispheric biFC, biCP, biPO and biTT locations, as well as for the left and right intrahemispheric FC-PO and TT-PO combinations. Power was highest in Q in the CP derivations at 0.4-12/s. Generally, power was higher in Q than in R. In most derivations, Q and R power ran parallel. W power behaviour was different. Up to 8/s, power in W was intermediate between Q and R power. From 10/s, it became highest, particularly in the TT and FC derivations. PO power was low. Highest coherence values occurred in the lowest frequencies. Up to 8/s, biFC, biCP and biPO interhemispheric coherences were highest in R and usually lowest during Q. In the alpha-beta range, highest coherences occurred during Q and lowest during R or W, without much variance between stages. BiPO coherences were remarkably high during all stages. BiTT and intrahemispheric coherences were low and less consistent. These data suggest high synchronization of theta-delta activity between biPO regions, particularly during R. We hypothesize active common generators of neonatal theta-delta activity in the posterior regions, indicating less autonomy and more interdependent behaviour of these areas especially during R.