Frequent handling in the neonatal intensive care unit and intraventricular hemorrhage.

The association between periventricular-intraventricular hemorrhage (PV-IVH) and frequent handling resulting from various neonatal intensive care procedures and routine interventions was evaluated in a prospective clinical study. Inborn premature babies with birth weight less than or equal to 1500 gm (n = 156) who did not have PV-IVH or who had grade 1 PV-IVH at less than or equal to 1 hour were randomly assigned to the reduced manipulation protocol (n = 62) or to standard care (n = 94). A bedside microcomputer-based data acquisition system was used to monitor the duration of rest or the number of interventions per day. Infants assigned to receive reduced manipulation spent a significantly higher percentage of time each day at rest than did those who received standard manipulation (p less than 0.006). However, the incidence of grades 2 to 4 PV-IVH did not differ significantly (30% in the study vs 37% in the standard manipulation group). When we analyzed the effect of manipulation in relation to risk of PV-IVH, while taking into account other perinatal variables, standard manipulation was not associated with increased risk of grades 2 to 4 PV-IVH. However, low birth weight, maternal smoking, general anesthesia, early grade 1 PV-IVH, low hematocrit, lowest arterial oxygen pressure within the first 6 hours of life, and large base deficit at 6 hours of age all increased the relative risk of grades 2 to 4 PV-IVH.

Indomethacin reduces the risks of severe intraventricular hemorrhage.

A prospective, random selection, double-blind clinical trial was carried out to determine the efficacy of indomethacin in preventing periventricular-intraventricular hemorrhage (PV-IVH). Babies who were born in our institution, had birth weights less than or equal to 1500 gm, and had no PV-IVH or grade 1 PV-IVH were given either placebo (n = 70) or indomethacin (n = 71), 0.2 mg/kg intravenously at 6 hours of age and 0.1 mg/kg at 18 and 30 hours. Two major outcomes were determined: the development of grades 2 to 4 PV-IVH and the development of severe PV-IVH (i.e., hemorrhages with blood filling greater than 50% of the ventricles and in some cases with associated parenchymal echodensities). Grades 2 to 4 PV-IVH occurred in 16 (23%) of the indomethacin group and 27 (39%) of the placebo group (p less than 0.03). The incidence of severe PV-IVH was 3% in the indomethacin-treated babies and 14% in the control group (p less than 0.02). The influence of other perinatal factors on the incidence of grades 2 to 4 or severe PV-IVH was determined by stepwise logistic regression. Placebo use, early grade 1 PV-IVH, lower birth weight, and higher fraction of inspired oxygen at 6 hours of life were associated with higher estimated odds of the development of grades 2 to 4 PV-IVH. Placebo use, male gender, lower 5-minute Apgar score, and a large base deficit were predictive of severe PV-IVH. Estimated odds ratios of severe PV-IVH with placebo use and male gender were 11.25:1 and 9:1, respectively. Thus indomethacin prophylaxis reduced the relative risk of grades 2 to 4 PV-IVH and severe PV-IVH, but other perinatal variables contributed significantly to the overall risk of PV-IVH.

Partial plasma exchange transfusion improves cerebral hemodynamics in symptomatic neonatal polycythemia.

Cerebral arterial pulsatile flow changes and the effect of partial plasma exchange transfusion on these pulsatile flow patterns were studied in neonatal polycythemia/hyperviscosity syndrome by transcutaneous Doppler technique. Twenty-two infants with cord blood hematocrit greater than 58% (greater than 2 SD above the mean) were studied from a total of 2,400 infants who were screened for cord hematocrit over a 6-month period. Each of 22 infants had the following initial studies: radial artery hematocrit, viscosity, intracranial pressure measurement, and anterior cerebral arterial Doppler study to determine pulsatility index, mean systolic, mean end diastolic, and mean flow velocities, and area underneath the curve of the velocity tracings/min. Twelve of 22 infants had radial artery hematocrit less than 63%, were normoviscous (less than 13.5 cps, 11.25 sec-1) and were designated as control infants. Ten (study infants) were polycythemic (hematocrit greater than or equal to 63%) and hyperviscous (greater than or equal to 13.5 cps, 11.25 sec-1). All study patients were treated by partial plasma exchange transfusion. Initial studies were repeated after exchange transfusion. Control infants were not treated. Prior to exchange procedure, the polycythemic hyperviscous infants had significantly higher hematocrit, viscosity, and pulsatility index; the other Doppler measurements and heart rate were lower than those of control babies. The exchange procedure resulted in significantly decreased hematocrit, viscosity, and pulsatility index and increase in the other Doppler measurements, heart rate, and intracranial pressure. All postexchange measurements of study infants were not statistically different from the control infants. These data suggest that neonatal polycythemia/hyperviscosity syndrome may be associated with abnormal cerebral hemodynamics that could improve with partial plasma exchange transfusion.

Heat shield reduces water loss.

A heat shield covered by polyvinyl chloride film greatly reduced insensible water loss and radiant energy requirements in 12 preterm infants on a radiant cradle. Measured transmittance of radiant energy emitted by the radiant heater was impeded minimally by various thin film plastics but was blocked significantly by Perspex.

Primary right ventricular tumor (fibroma) simulating cyanotic heart disease in a newborn.

The clinical, echocardiographic, cineangiocardiographic and autopsy findings in a newborn infant with right ventricular fibroma are reported. The tumor caused severe right ventricular outflow obstruction simulating cyanotic heart disease. Echocardiography allowed a definitive diagnosis of the tumor mass at 10 hours of age. The clinical implications of the case are discussed.

Thermal management in the care of sick neonates: a clinical appraisal.

The neonate's thermal stability is limited by a propensity for losing heat rather than an inability to generate it. The smaller the infant, the greater the expected thermal losses to the environment. The resultant vulnerability to hypothermia may diminish a sick infant's chances of survival. Radiant warmers and incubators are used in the nursery to regulate the infant's heat loss, yet each device has inherent advantages and disadvantages. By protecting the baby from air movement in the nursery and reducing insensible water loss to acceptable levels, plastic shields can eliminate the principal objections to prolonged use of radiant warmers for neonatal intensive care.