Effect of nursing position on incidence, type, and duration of clinically significant apnoea in preterm infants.

AIM: To investigate whether nursing position has any effect on the frequency, type, and duration of apnoeas in preterm infants. METHOD: Thirty five preterm infants were entered into a crossover study and underwent polygraphic monitoring in each of two positions, prone and supine, the initial position being randomly allocated. Four parameters were recorded: nasal airflow, respiratory effort, electrocardiogram (ECG), and oxygen saturation. Each infant was studied in the two positions on the same day and each infant was studied only once. The studies were carried out on the neonatal intensive care unit. RESULTS: The infants were found to have significantly more central and mixed apnoeas in the supine than in the prone position. In addition, the severity of mixed apnoeas in terms of the duration of accompanying bradycardias and desaturations was greater in the supine than in the prone position (median difference 5.1 seconds in both instances). When considering the type of apnoea in relation to the duration, it was found that of those less than 20 seconds in duration there was a greater proportion that were central (25%) compared with the proportion of central (5%) apnoeas that were longer than 20 seconds. Of all the apnoeas that were less than 20 seconds in length, 16% were obstructive and 59% were mixed, whereas of the apnoeas greater than 20 seconds, 13% were obstructive and 82% were mixed. CONCLUSIONS: It appears that in addition to improving measures of lung function, the adoption of the prone nursing position for preterm infants may reduce associated problems of apnoea of prematurity.

Infants with chronic lung disease: predictors of mortality at day 28.

The outcome of infants who were admitted to the neonatal intensive care unit at Liverpool Maternity Hospital between January 1980 and December 1989 and who developed chronic lung disease (n = 242) was determined. Forty-three (18%) died in hospital and 18 (9% of survivors) were discharged with home oxygen therapy. The number of days spent receiving supplementary oxygen significantly correlated with the number of days of ventilatory support received and the inspired oxygen concentration on day 28. Logistic regression analysis revealed that death in the hospital was independently associated with being male, and correlated with the number of days of ventilatory support received and the inspired oxygen concentration on day 28. An equation that predicted the probability of death in infants with chronic lung disease was derived and was validated for infants with chronic lung disease at another center (Nottingham). This equation may be useful clinically and for research.

An assessment of a new breath actuated inhaler device in acutely wheezy children.

A randomised double blind, two period cross over study was designed to compare the ability of 51 hospitalised asthmatics with acute exacerbations to use each of two inhalers. The inhalers compared were a new breath actuated metered dose inhaler, the Autohaler inhalation device, and a dry powder device, the Rotahaler. Preassessment data included the measurement of peak inspiratory flow rate (PIFR), peak expiratory flow rate (PEFR), pulse rate, and oxygen saturation. Therapeutic response to each inhaler was compared by measurement of PEFR, oxygen saturation, and pulse rate. PIFR was sufficient in all children to fire the Autohaler, including the youngest. No significant difference was found between the two inhalers as assessed by PEFR. However the Autohaler inhalation device could be actuated 99/100 times successfully compared with 74 for the Rotahaler. There was a consistent, but clinically insignificant, increase in pulse rate after use of the Rotahaler compared with the Autohaler. All 11 patients under 6 years of age failed to empty the Rotahaler but five of these patients received a significant benefit from using the Autohaler compared with after the Rotahaler. A significant drop in oxygen saturation was observed 15 minutes after use of either inhaler. This may at times reach levels of clinical importance.

Site of upper airway obstruction in infants following an acute life-threatening event.

Twenty-five patients were screened following an acute life-threatening event for the presence of obstructive and mixed apnea. Simultaneous cardiorespiratory monitoring with fiberoptic laryngoscopy was performed to identify the site of upper airway obstruction during these episodes. In 3 of these subjects, who had been born prematurely, obstruction was observed at the laryngeal level, with the arytenoid masses and aryepiglottic folds closing over across the vocal cords. Such closure was also observed during periodic breathing, which was found to be prominent in 4 of the infants studied. The possible role of laryngeal reflexes as a mechanism for these events is discussed.

Lethal skeletal dysplasia owing to double heterozygosity for achondroplasia and spondyloepiphyseal dysplasia congenita.

A male infant with lethal short limbed dwarfism is described. His father had spondyloepiphyseal dysplasia congenita and his mother had achondroplasia. It is believed that the infant inherited both of these disorders and that their combined effects resulted in early death owing primarily to severe pulmonary hypoplasia.

Inhaled budesonide for chronic wheezing under 18 months of age.

The role of budesonide in controlling chest symptoms in infants was assessed. It was administered from a metered dose inhaler into a large volume spacer (Nebuhaler) with attached Laerdal mask. Twenty nine infants were recruited into a double blind crossover trial. Five defaulted. The remaining 24 (mean age 11 months) were assessed for the tolerance of the device, adverse effects, treatment failures, parental opinion, and daily symptom and treatment records. Twenty tolerated the modified Nebuhaler. One developed meningitis on placebo. Two experienced exacerbations on placebo. Eleven of 18 parents whose children completed the maximum treatment preferred budesonide to placebo and one preferred placebo. Mean symptom scores on budesonide were better than on placebo for the 15 children with complete symptom records. Fewer bronchodilator doses were used while taking budesonide. Our findings indicate that budesonide given in this way is an effective treatment for infants who may need prophylaxis for their wheezing.

Site of upper airway obstruction in preterm infants with problematical apnoea.

Airway obstruction is an important factor predisposing to the development of apnoea in preterm infants. An ultrafine fibreoptic scope was used to examine the upper airway of 12 preterm infants with recurrent problematical apnoea. Continuous visualisation of the airway was possible and recorded on to videotape together with simultaneous cardiorespiratory monitoring to detect apnoeic episodes in 12 infants studied. In seven infants obstruction was observed at laryngeal level with the arytenoid masses and aryepiglottic folds closing across the vocal cords. This was not only observed in obstructive apnoea but also during mixed apnoea in periods where no respiratory effort was detectable and again in apparently pure central apnoea. The findings confirm the larynx as an anatomical site of upper airway obstruction. They agree with other indirect methods of assessing airway patency that obstruction has an important role in the pathophysiology of apnoea of prematurity.

Malignant melanoma in childhood.

Only two cases of malignant melanoma in childhood have previously been reported in this Journal (Olbourne and Harrison, 1974; Keall et al., 1981). The report describing 31 cases in the Manchester area (Pratt et al., 1981) indicates that this condition may be more common in this country than previously supposed. A case of malignant melanoma arising in a mole in a 23 month male child is reported. A review of the literature shows that there are no survival figures for cases without metastasis but at present there is no reason to suspect that the disease is any less aggressive than in adults. It cannot be stressed too often that any mole with rapid growth, ulceration, bleeding with minimal trauma and change in colour should be biopsied urgently irrespective of the age of the patient.