Retention of neonatal resuscitation skills and knowledge: a randomized controlled trial.

BACKGROUND AND OBJECTIVES: This study compared the effectiveness of two booster strategies designed to improve retention of skills and knowledge in neonatal resuscitation by family practice residents. METHODS: Residents were randomly allocated to one of three groups: video, hands on, or control. Residents in the two experimental groups received a "booster" 3-5 months after the Neonatal Resuscitation Program (NRP) course. All participants completed the follow-up test 6-8 months after taking the course. The main outcome measures consisted of the NRP written examination and the performance checklists. RESULTS: A total of 44 residents completed the study (video, n = 13; hands-on, n = 14; control, n = 17). Overall, participants had significantly lower scores at follow-up than at baseline, indicating deterioration in both neonatal skills and knowledge. Residents in the hands-on booster group made significantly fewer errors across all five checklists in life-supporting but not in lifesaving scores than those allocated to the control and video groups. CONCLUSIONS: The beneficial effect of mannequin practice or video boosters on skills and knowledge retention was less than what had been anticipated, and no benefit could be demonstrated in comparison to the control group. Deteriorating knowledge and skills remain a major concern, since boostering by hands-on or video at 3-5 months do not seem to have an impact on the retention of knowledge or lifesaving skills.

Long-term pulmonary sequelae of severe bronchopulmonary dysplasia.

OBJECTIVE: To evaluate the long-term pulmonary sequelae of survivors of bronchopulmonary dysplasia (BPD) of sufficient severity to have required supplemental oxygen for at least 1 month after term. STUDY DESIGN: Fifteen patients with a mean age of 1.1 years were matched to preterm infants of similar gestational age and age at time of study. Pulmonary function testing included spirometry, plethysmographic lung volumes, carbon monoxide diffusion capacity, and in 9 of 15 subjects with BPD, measurement of lung static elastic recoil pressures. RESULTS: The subjects with BPD had a mean expiratory volume in 1 second (FEV1) of 64% +/- 21% predicted (4 had an FEV1 < 50% predicted) compared with 85% +/- 11% (P < .01) for the preterm children in the control group. Subjects with BPD had a significant degree of gas trapping with a residual volume to total lung capacity ratio of 37% +/- 13% compared with 25% +/- 4% for the control group (P < .01). An inverse relationship was seen between the FEV1 and the time on supplemental oxygen (r = -0.84, P < .0001), with 3 of the 4 children whose FEV1 was < 50% requiring oxygen for more than 900 days. Those with the greatest degree of airflow limitation and gas trapping had the greatest abnormalities in both shape and position of the pressure volume curves of the lung. CONCLUSION: Severe BPD may result in moderate to severe long-term abnormalities in pulmonary function tests.

Dexamethasone for pulmonary interstitial emphysema in preterm infants.

The efficacy of a 3-day course of dexamethasone (0.5 mg/kg/ day) in 10 preterm infants (< or = 30 weeks gestation) with pulmonary interstitial emphysema (PIE) was studied in a retrospective case review. PIE was diagnosed at a median age of 7.5 days and treatment with dexamethasone began at 8.5 days. Seven of the 10 subjects had at least 2 days of conservative treatment (lowered mean airway pressure) preceding dexamethasone during which the mean airway pressure (MAP), oxygenation index (OI) and mechanical ventilation index (MVI) were not significantly different although within 3 days of dexamethasone each variable improved significantly (p < 0.05). Similarly, for all 10 infants, OI and MAP were significantly lower at 3 and 7 days from baseline (p < 0.005). By day 7, FiO2 (p = 0.022) and MVI (p = 0.011) were significantly lower and PIE had resolved on chest X-ray in 7/9 (78%) and improved in the remaining 2/9 (22%). Nine of the 10 infants survived to term. Three days of dexamethasone was associated with significant clinical improvement in most of these infants. The mechanism may relate to reduced airway oedema and inflammation and reduced airway obstruction.

Exercise ability in survivors of severe bronchopulmonary dysplasia.

There is limited information concerning the exercise performance of long-term survivors of bronchopulmonary dysplasia (BPD), and much of what is available pertains to those with relatively mild disease. The present study was undertaken to describe exercise responses in patients with a history of severe BPD, defined as those patients with a clinical and radiographic diagnosis of BPD who required supplemental oxygen at least until they were 44 wk postconceptual age and who were discharged home on oxygen. Fifteen children with a history of severe BPD were matched for gestational age with 15 children who had previously had respiratory distress syndrome but who did not develop BPD (Prem). These Prem control children were subsequently compared with 13 healthy control children born at term (Control) who were of similar postnatal age. Participants underwent pulmonary function testing, progressive exercise testing on a cycle ergometer, and a steady-state exercise test with cardiac output determined by CO2-rebreathing. Despite the patients with BPD having a lower FEV1 than those in the Prem group, who had lower values than the Control group (BPD, 64 +/- 21%; Prem, 85 +/- 11%; Control, 95 +/- 8%), the exercise capacity did not differ between the BPD and the Prem and between the Prem and the Control groups (BPD, 84 +/- 15%; Prem, 81 +/- 17%; Control, 91 +/- 12%). However, the BPD patients used a greater percentage of their ventilatory reserve (VEmax/40 FEV1: BPD, 93 +/- 20%; Prem, 67 +/- 12%; Control, 59 +/- 13%). Of the four patients with BPD who had significant oxygen desaturation with exercise, three had the lowest values for FEV1. Cardiac output was appropriate for oxygen consumption in most patients.

Knowledge gained following Neonatal Resuscitation Program courses.

BACKGROUND: This study evaluated the knowledge gained and retained by family practice residents who participated in the Neonatal Resuscitation Program (NRP) course. METHODS: Knowledge attainment and its retention was assessed by the administration of pre-, post-, and 6-month follow-up tests using the standard NRP written examination. Twenty-nine residents from the Department of Family Medicine at McGill University completed the pretests and posttests, and 10 of these completed the follow-up tests. The data were analyzed using repeated measures analysis of variance and Student's t tests. RESULTS: The average score was 60.6% (n = 29) for pretest, 90.7% (n = 29) for posttest, and 75.4% (n = 10) for the follow-up test. A significant improvement was shown in posttest examination scores when compared to pretest scores and in the follow-up test scores when compared to pretest scores. No significant difference existed between the posttest and follow-up test scores. However, small sample size may have prevented detection of significant differences. Further, follow-up scores for some subjects had fallen to below the level required to pass the course. CONCLUSIONS: The results suggest that participation in an NRP course significantly increased knowledge of neonatal resuscitation by family practice residents, but that knowledge may decrease over time.

Postnatal maturation of the blood-brain barrier for unbound bilirubin in newborn piglets.

The postnatal maturation of the blood-brain barrier (BBB) for unbound bilirubin was studied in 2-day- and 2-week-old piglets. Hyperbilirubinemia was induced by bolus infusion of bilirubin at 25 mg/kg followed by continuous infusion of 20 mg/kg/h for 3 h. During the study period, arterial blood pH and blood gas tensions, serum osmolarity, and mean arterial blood pressures were within the physiologic range. Brain bilirubin content and the brain/blood distribution ratio for bilirubin were higher in the 2-day-old than in the 2-week-old piglets. In both age groups, regional brain bilirubin concentration and brain/blood ratios were higher in subcortical regions (cerebellum and brainstem) than in the cerebral cortex. We conclude that in newborn piglets the blood-brain barrier for unbound bilirubin matures with increasing postnatal age and that irrespective of maturity the relative permeability of the BBB for bilirubin appears higher in subcortical than in cortical regions.

Portohepatic shunt in a Down syndrome patient with an interchange trisomy 47,XY,-2,+der(2),+der(21)t(2;21)(p13;q22.1)mat.

A rare vascular portohepatic anomaly was identified in a Down syndrome patient with a 47,XY,-2,+der(2),+der(21)t(2;21)(p13;q22.1) mat chromosomal complement. This vascular defect involves a direct communication between the right portal vein and the inferior vena cava (IVC). We discuss the possibility that this vascular defect is a rare manifestation in Down syndrome. Alternatively, the existence of these 2 rare events in the same patient raises the possibility that they are causally related.

Aminopterin-like syndrome sine aminopterin associated with translocation involving chromosomes 5 and 10.

We studied a baby born with physical features suggestive of the aminopterin syndrome, but without exposure of the mother to aminopterin during pregnancy. G-banded chromosomes from peripheral blood lymphocytes had a normal 46,XX pattern. However, in 50 skin fibroblasts there was a normal female karyotype in 5 cells and 45 cells showed an apparently balanced reciprocal translocation involving the long arm of chromosome 5 (band q35) and the long arm of chromosome 10 (band q22). The relation of this mosaicism to the abnormal phenotype is unclear.

Liquid-filled esophageal catheter for measuring pleural pressure in preterm neonates.

The precise measurement of esophageal pressure (Pes) as a reflection of pleural pressure (Ppl) is crucial to the measurement of lung mechanics in the newborn. The fidelity of Pes as a measurement of Ppl is determined by the occlusion test in which, during respiratory efforts against an occlusion at the airway opening, changes in pressure (delta Pao) (Pao is assumed to be equal to alveolar pressure) are shown to be equal to changes in Pes (delta Pes). Eight intubated premature infants (640-3,700 g) with chest wall distortion were studied using a water-filled catheter system to measure Pes. During the occlusion test, all patients had a finite region of the esophagus where delta Pes equaled delta Pao, which corresponded to points in the esophagus above the cardia but below the carina. In conclusion, even in the presence of chest wall distortion, a liquid-filled catheter with the tip between the cardia and carina can provide an accurate measurement of Ppl, even in the very small premature infant with chest wall distortion.

Family support system in newborn medicine: does it work? Follow-up study of infants at risk.

Acute illness in early childhood generates chronic anxiety in parents, which may manifest itself in part by inappropriate use of health care. To minimize this and the development of other psychosocial sequelae associated with neonatal illness, a family support system (FSS) was developed and implemented in a neonatal intensive care unit. The effectiveness of the FSS was assessed by the evaluation of emergency room and inpatient hospital service utilization in 80 patients born before, and 90 patients born after the institution of the program. At the outset, the groups had similar medical and social characteristics. There was no difference between the two groups in the utilization of emergency services in the first year after discharge. However, during the second year the control group used the emergency room twice as often as the study group did (P less than 0.025). During the first 2 years, half of the control group was readmitted, compared with less than a third of the study group (P less than 0.005). Overall, after discharge from the neonatal intensive care unit the control group spent an average of 9 days per patient in hospital, compared with a mean of 3 days per patient in the study group (P less than 0.025). It appears, therefore, that the FSS may be an effective way to reduce some of the psychosocial sequelae of illness in newborn infants requiring intensive care.

Interaction of caffeine and continuous distending airway pressure in neonatal apnea.

The interactive effect of caffeine and continuous distending airway pressure was evaluated in two premature neonates with apnea. The application of a continuous negative pressure around the chest wall decreased minute ventilation in both infants and blunted the stimulatory effect of caffeine. This potential interaction should be considered if the desired effects of caffeine or distending airway pressure on apnea control are not achieved when they are used concurrently.

Outcome at school-age after neonatal mechanical ventilation.

103 school-age children (5 to 12 years) who survived mechanical ventilation for neonatal respiratory failure were evaluated for growth, neurological, intellectual, psychological and school function in order to determine those children most at risk for handicap. A major handicap occurred in seven children, preventing attendance at normal school or normal classes. Neurological sequelae were significantly associated with perinatal asphyxia and with birthweights of 1500g or less, and neurological sequelae and socio-economic factors were the major determinants of ability. The effects of the Neonatal Intensive Care Unit (NICU) experience on parents and subsequent parent-child relationships were also investigated: 67 per cent of the mothers were very upset by the experience and many continue to worry excessively about the health of their child. Parents who visited their child in the NICU frequently were significantly more anxious and overprotective, restricting many activities even when the child was of school age.

Epidemiology of adverse drug reactions in the newborn.

A prospective study on the epidemiology of adverse drug reactions (ADR) in the 200 neonates consecutively admitted to a newborn intensive care unit had shown that 136 ADR occurred in 60 babies (incidence = 30%). 20 of these ADR (14.7%) were major (life-threatening), 34 (25%) were moderate (prolonged hospital stay) and 82 (60.3%) were minor (resolved spontaneously, no therapy required). Respiratory depression, cardiac arrhythmias, renal failure, metabolic abnormalities (hyperglycemia, electrolyte imbalance) and gastrointestinal bleeding were the most common major and moderate ADR. Hematologic (eosinophilia, thrombocytopenia) and metabolic (lipemia, hyperglycemia) were the most frequent minor ADR. The case fatality rate is 5%. Most commonly suspected drugs associated with the ADR were cardiovascular drugs (tolazoline, digoxin, methoxamine), antibiotics, diuretics and components of intravenous nutrition solutions.

Blood transfusion: a possible risk factor in retrolental fibroplasia.

The effect of blood transfusion on the occurrence of RLF was evaluated in 58 infants who weighed less than 1001 g at birth (Group I) and 70 oxygen treated infants of various birth weights (Group II). Although there was no significant difference between Group I infants with or without exchange transfusion as to birth weight, gestational age, duration of oxygen therapy, peak Pa02's, or multiple births, there was a significantly increased incidence of pre-retrolental fibroplasia in transfused over non-transfused Group II infants. When Group II infants were stratified for prematurity and oxygen duration, this difference persisted in those not already at risk for RLF. This increased incidence of retinopathy in transfused infants suggests that blood transfusion may be a risk factor in the pathogenesis of RLF.

Risk factors in retrolental fibroplasia.

Possible determinant factors that may increase the risk of the occurrence of retrolental fibroplasia (RLF) were analyzed in 80 infants born in 1975 and 1976 with birth weights between 501 and 1,500 gm and who survived. Active and/or cicatricial RLF occurred in 27 (33.8%) infants and the factors significantly associated with RLF were: gestational age (P less than .001); apnea requiring bag and mask resuscitation with oxygen (P less than .001); septicemia (P less than .005); degree of illness; blood transfusion; and mechanical ventilation. Severe cicatricial RLF developed in eight (10%) infants (grades 2 to 5). In the group of infants all of whom had apnea which required resuscitation, septicemia was also significantly associated with RLF (P less than .01). A highly significant association between RLF and severe myopia (P less than .001) was found in follow-up in all infants. Data show a resurgence and high incidence of RLF in low birth weight infants who survived. Infants with these factors should be considered to have greater risk for the occurrence of RLF and ophthalmologic examination prior to, and within three months following discharge is recommended.

Pharmacokinetic profile of caffeine in the premature newborn infant with apnea.

The pharmacokinetic profile of caffeine was studied in 32 premature newborn infants with apnea: 12 following a single intravenous dose; 3 after a single oral dose; 7 during treatment with an initial empirical (high) maintenance dose schedule; and 10 during treatment with a revised (lower) dose schedule. Mean (+/- SE) AV d, t 1/2, ke1, and clearance following a single intravenous dose were 0.916 +/- 0.070 1/kg, 102.9 +/- 17.9 hours, 0.009 +/- 0.001/hours and 8.9 +/- 1.5 ml/kg/hour, respectively. Rapid absorption was noted with plasma concentrations of 6 to 10 mg/l achieved within 30 minutes to two hours following an oral dose of 10 mg/kg. Cpss of caffeine in infants given a high empirical dose (11.2 +/- 1.5 mg/kg/day) ranged from 22.5 to 84.2 mg/l (mean = 45.3) whereas a dose schedule based on kinetic data (2.5 mg/kg/day) yielded plasma concentrations ranging from 7.4 to 19.4 mg/l (mean = 13.7). We suggest a loading dose of 10 mg/kg intravenously or orally followed by a daily maintenance dose of 2.5 mg/kg/day administered as a single dose for the treatment and prevention of neonatal apnea.