Hemopericardium and cardiac tamponade as presenting findings of dexamethasone-induced hypertrophic cardiomyopathy complicated by transmural myocardial infarction.

This is the first report of dexamethasone-induced left ventricular outflow obstruction causing decreased coronary artery perfusion and apical transmural cardiac infarct that resulted in hemopericardium and rapid cardiac tamponade. The differential diagnosis of hemorrhagic pericardial effusion must now include dexamethasone-induced hypertrophic cardiomyopathy.

Plasma amino acid patterns in very low birth weight infants during parenteral nutrition.

Plasma amino acids were measured in eight very low birth weight infants (less than or equal to 1000 gm) before and after infusion of parenteral alimentations with Freamine III. Significant elevation in serum threonine, valine, isoleucine, methionine, serine, proline, glycine and ornithine was noted after twenty four hours of infusion. On the other hand, significant decreases in taurine and tyrosine levels were noted. Our study suggests that current solution is not optimal for premature neonates and the amount of protein administered during the first week in infants weighing less than or equal to 1000 gm should be decreased from the recommended 2.5-3.0 gm/kg/day.

Green vomiting in the first 72 hours in normal infants.

From June 1980 to September 1984, forty-five newborns (weight greater than or equal to 2000 g), initially presumed normal, were seen with bilious vomiting in the first 72 hours and were prospectively followed up. Nine (20%) required surgical intervention, five (11%) had nonsurgical obstruction such as meconium plug or left microcolon, and the remaining 31 (69%) had idiopathic bilious vomiting. Infants with idiopathic bilious vomiting had a benign transient course and resumed feedings by 1 week of age; 30 of the 31 had normal or nonspecific findings on initial plain abdominal roentgenogram. Specific findings on the initial plain abdominal roentgenogram were noted in five infants, and four (80%) of these had a lesion requiring surgical intervention; 56% (5/9) of neonates with surgical lesions had normal or nonspecific findings on the plain abdominal roentgenograms. None developed bowel ischemia or midgut infarction secondary to a volvulus as they were identified by contrast studies shortly after the initial episode of bilious vomiting. Although the majority of "normal" neonates with bilious vomiting do not have a surgical lesion, this study indicates that 56% of surgical cases will be missed if contrast studies are not done.

Decreased plasma glucose following indomethacin therapy in premature infants with patent ductus arteriosus.

The effect of indomethacin on carbohydrate metabolism was studied in six premature infants with significant patent ductus arteriosus (mean +/- S.D., birth weight 1,066 +/- 244 gm, gestational age 30 +/- 1.6 weeks). All infants were in a glucose steady state between 50 and 100 mg/dl over a 2-hour period before indomethacin administration. There was a significant fall in plasma glucose at 1, 6, 12, and 24 hours following intravenous indomethacin infusion. Since there was no significant change in insulin levels from the baseline, the mechanism of indomethacin-mediated lack of prostaglandin inhibition of insulin release was not substantiated. Based on this study, plasma glucose levels should be followed closely in the first 24 hours following intravenous indomethacin administration.

Increased O2 consumption and energy loss in premature infants following medical care procedures.

Oxygen consumption (VO2) and CO2 production (VCO2) were measured continuously for 24 h in 10 premature infants during their ongoing nursing care. Using a flow-through technique, the total VO2 and VCO2 over a given period of time were determined from the area under the O2-and CO2-concentration-time curve of the mixed expired gas. Following chest physiotherapy, heel stick and i.v. needle insertion, there was a significant (p less than 0.01) increase in VO2 and VCO2. When measured for 24 h, the total daily increase of VO2 attributed to these procedures ranged from 2.1 to 11.7% of total daily VO2, equivalent to an estimated energy loss of 0.6-4.1 kcal/kg/day.

Penicillin in infants weighing two kilograms or less with early-onset Group B streptococcal disease.

We studied the effect of penicillin on early-onset Group B streptococcal disease over a 52-month period in neonates who were at high risk of infection. Shortly after birth, 1187 neonates weighing 2000 g or less had blood samples taken for cultures and were randomized into an early-treatment group (given intramuscular penicillin G within 60 minutes of birth) or a control group. The incidence of early-onset disease was 20 per 1000 live births (24 of 1187); the number of infants in the early-treatment group who had disease (10 of 589) was similar to that in the control group (14 of 598). The fatality rates were similar in both groups (6 of 10 vs. 8 of 14). Cultures from blood obtained with one hour of birth were positive in 21 of the 24 infants with disease; 22 of the 24 were symptomatic within four hours of birth. Thus, infection was well established before the first hour of postnatal life. At autopsy, gram-positive cocci were seen in lung sections of four infants in whom cultures of blood obtained after treatment had been sterile; this indicates that giving routine antibiotic therapy before culture samples are obtained can obscure bacteriologic diagnosis. We conclude that penicillin given at birth to neonates weighing 2000 g or less does not prevent early-onset streptococcal disease or reduce excess mortality associated with disease.

Lung volume, dynamic lung compliance, and blood gases during the first 3 days of postnatal life in infants with meconium aspiration syndrome.

Serial measurements of pulmonary function and arterial blood gases during the first 3 postnatal days of life were obtained in 12 infants with meconium aspiration syndrome (MAS). Nine normal neonates with similar weight and gestational age were studied as controls. Infants with MAS has significantly lower pH on day 1, and had greater P(A-a)O2 throughout the study period than that of normal controls. The PCO2 was comparable between the groups. Both dynamic lung compliance (Cdyn) and specific lung compliance (C/VL) were lower in infants with MAS as compared with those of normal infants. The functional residual capacity (FRC) for normal infants on days 1, 2, and 3 were 2.0 +/- 0.3, 2.1 +/- 0.3, and 2.2 +/- 0.3 ml/cm, respectively, and for infants with MAS were 1.8 +/- 0.4, 2.3 +!- 1.1, and 2.2 +/- 0.6 ml/cm, respectively. Radiographic hyperinflation of the lungs was seen in 6 infants with MAS on day 1; 3 were associated with high FRC (greater than 2 SD of normal) and 2 with low FRC, indicating air trapping. The early use of PEEP should be cautious if hyperinflation or air trapping is present.

Decreased plasma glucose following indomethacin therapy in premature infants with patent ductus arteriosus.

In the course of a double-blind controlled trial of intravenous indomethacin therapy in premature infants with patent ductus arteriosus, plasma glucose was evaluated in 47 infants before and at 24, 48, and 72 hours following the medication. Twenty-two infants were assigned to the control group and 25 were in the indomethacin group. Significantly lower plasma glucose was noted at 24 (P less than 0.01) and 48 (P less than 0.05) hours in the indomethacin group as compared to the control group. There was a significant inverse correlation between the plasma glucose and the corresponding plasma indomethacin concentration (P less than 0.05) and between the plasma glucose and the corresponding plasma indomethacin concentration-time integral (P less than 0.01) at 24, 48, and 72 hours after drug administration, suggesting that the decreased plasma glucose may be related to indomethacin therapy. The results of this study indicate that endogenous prostaglandin may play a role in glucose homeostasis in premature infants.

Fever in full-term newborns in the first four days of life.

Over a period of 18 months, 100 full-term newborns developed an axillary or a rectal temperature greater than or equal to 37.8 C during the first four days of postnatal life. These febrile term newborns represented 1% of all full-term newborns in the normal nursery. Of the febrile newborns, 10% had culture-proven bacterial disease (BD). Fever developed in 54%, 27%, 13%, and 6% on the first, second, third, and fourth days, respectively. In 17 newborns fever developed within the first hour of life; 13 of these had mothers with fever and two others were under a radiant warmer in the birth room. Fever occurring on the third day of postnatal life had a significantly higher chance of being associated with BD than fever occurring at any other time in the first four days of postnatal life. Newborns with temperature greater than or equal to 39 C had a significantly higher incidence of BD than newborns with temperature less than 39 C. The incidence of fever among breast-fed newborns (0.98%) was similar to that of formula-fed newborns (1.01%). Of the 100 febrile newborns, 45 had other symptoms compatible with BD, and eight of these had proven BD (group B Streptococcus in five, group D Streptococcus in one, Shigella D in one, and Propionibacterium species in one). The two other febrile newborns with proven BD had no other symptoms of infection (group B Streptococcus and Escherichia coli). Mean WBC count of febrile newborns with BD was significantly lower than that of febrile newborns without BD. Only three febrile newborns had WBC count less than 5,000/cu mm and two of them had proven BD. Febrile newborns should be evaluated and treated with antibiotics when they have symptoms of infection other than fever or when the fever persists or recurs.

Oxygen concentration gradients in the special care nursery.

Room-air oxygen concentration in the respiratory care areas of our Special Care Nursery ranged from 20.9% to 24.8%. Calculated oxygen concentrations in our respiratory care areas, assuming an air turnover of five or 12 air changes per hour, were frequently far below observed concentrations. This indicated that ventilation in our respiratory care areas provided below minimum recommended number of air changes per hour. Therefore, in respiratory care areas in older structures with poor ventilation or with ventilatory system breakdown, environmental oxygen should be monitored.

Oxygen consumption and insensible water loss in premature infants in single-versus double-walled incubators.

Fifteen studies were performed in ten premature infants whose birth weight (mean +/- SD) was 1,444 +/- 250 gm, gestational age 32.7 +/- 1.0 weeks, and postnatal age 10.7 +/- 3.3 days. Each study consisted of three hours simultaneous measurement of insensible water loss and oxygen consumption under two conditions for the same infant: (1) inside a single-walled incubator and (2) inside a double-walled incubator. The double-walled incubator provided significantly (P < 0.001) higher operative temperature and incubator wall temperature than did the single-walled incubator. Infants inside the double-walled incubator had significantly lower (P < 0.01) IWL (30% reduction) and lower (P < 0.05) VO2 (17% reduction) than inside the single-walled incubator--a net caloric saving of 11.8 kcal/kg/day. This saving of energy expenditure may be important in affecting the growth and outcome of the low-birth-weight infants.

Group B streptococcal osteomyelitis and septic arthritis. Its occurrence in infants less than 2 months old.

Nine infants less than 2 months of age with group B streptococcal (GBS) osteomyelitis or septic arthritis, or both, were seen from January 1975 through January 1978. The infants had local joint signs, usually in the absence of systemic signs. The bones and joints involved were equally distributed between proximal humerus and proximal and distal femur. An infant had involvement of the talus. Treatment consisted of two to three weeks of parenteral antibiotics, arthrotomy in infants with arthritis, and bone decompression in infants with osteomyelitis. Clinical follow-up showed normal growth and function of the affected joint. Of the organisms, five were typed: four were type III and one was type Ib. Group B streptococcal osteomyelitis and/or septic arthritis was the second most common late-onset GSB infection, being surpassed only by meningitis.