Rapid estimation of insertional length of endotracheal intubation in newborn infants.

OBJECTIVE: To create a simple and accurate method of predicting the correct insertional length of endotracheal intubation during resuscitation of neonates. STUDY DESIGN: Phase I of the study enrolled infants that required either orotracheal or nasotracheal intubations. The endotracheal tube position was confirmed by auscultation and radiographic images. Three regression equations were then created using nasal-tragus length, sternal length, and birth weight on insertional length. In phase II of the study, the modified regression equations of nasotracheal and sternal length were used to predict endotracheal tube insertional length in 50 infants (40 orotracheal and 10 nasotracheal). RESULTS: Nasal-tragus length and sternal length are good parameters to estimate insertional length for endotracheal intubation (p < 0.005 for both the parameters). The modified prediction equation for insertional length of the endotracheal tube for the orotracheal route is NTL or STL + 1. For the nasotracheal route the equation is NTL or STL + 2. CONCLUSION: During resuscitation of the neonate when vital parameters are difficult to obtain, the insertional length of endotracheal intubation can be quickly and accurately predicted by nasal-tragus length or sternal length.

Percutaneous peritoneal drainage in the management of acute intestinal perforation.

This case series describes the use of percutaneous peritoneal drainage when it is performed as the definitive treatment for acute intestinal perforation. Seven extremely low birth weight neonates who were admitted to a neonatal intensive care unit of a regional center between March 1987 and October 1992 had acute intestinal perforation. Six neonates were initially treated with percutaneous peritoneal drainage while they were under local anesthesia. Despite reports that percutaneous peritoneal drainage alone can be curative in intestinal perforation, this approach without adjunctive surgery can delay the recovery of bowel integrity.

Decreased respiratory tolerance from intermittent asphyxia in rat sucklings.

To study the respiratory tolerance of rat pups to intermittent asphyxia induced by exposure to closed rebreathing, we randomized newborn rats from four litters into two treatment groups. Respiratory tolerance was defined as the time interval during asphyxia until the first episode of 30 seconds of apnea. Rats in the experimental group were asphyxiated once daily during the first 4 days of life. Rats in the control group were asphyxiated once on day 4 of life. Pups exposed to intermittent asphyxia had a significant reduction in respiratory tolerance compared with that of littermates asphyxiated once at the same age. These findings suggest that the ability of the young mammal to withstand re-exposure to asphyxia may be impaired.

Effect of adding heparin in very low concentration to the infusate to prolong the patency of umbilical artery catheters.

A randomized controlled study was done to determine whether the addition of heparin, in very low concentration (0.25 U/ml), to fluids administered through an umbilical artery catheter (UAC) would affect the duration of catheter patency. UAC occlusion occurred in 2 of 15 patients in the heparin group and in 11 of 15 patients in the control group (p = 0.001). Using life-table analysis, the functional life span of UAC was estimated. On day 8, 100% of UACs in heparin group and 9% of UACs in control group were patent (p < 0.05). Coagulation profile remained unaltered after addition of heparin compared with that before the start of the therapy. There was no difference in the incidence of subependymal intraventricular hemorrhage between the two groups. It is concluded that heparin in such low concentration is effective in prolonging duration of UAC patency without causing adverse effects.

Discrepancies in birth weights between hospital records and health department data for low birth weight infants in New York City.

The study is one of the first to compare corresponding birth weights documented on New York City Health Department Vital Statistics (HDVS) birth tapes and the neonatal medical records of the hospital of birth. Only those infants with birth weights of 2,500 grams (g) or less were studied. Analyses were made of the scope, magnitude of error, and direction of the discrepancies observed. Concordance was considered present if the discrepancy in birth weight was 30 g or less. HDVS birth tapes and the hospital charts of 3,864 neonates were reviewed. The study population came from 48 of 53 hospitals in the metropolitan area. Hospitals were divided into three categories by the level of care offered. Each level of care was subdivided into groups by type of hospital ownership, that is, proprietary, voluntary, and municipal. Concordance was 87 percent overall and ranged from 67 to 96 percent among the study hospitals. More discrepancies were found for levels II and III hospitals than in level I hospitals, those with less sophisticated resources. Municipal hospitals had more discrepancies in birth weights than voluntary hospitals. Infants who had been transported from the birth facility to another facility had significantly higher concordance rates than the nontransported infants, after adjusting for levels of care, type of ownership of the hospital, and birth weight categories. Increased concordance rates were shown to be associated with increased birth weights.

Effectiveness of neonatal transport in New York City in neonates less than 2500 grams--a population study.

In the past two decades, there has been a gradual trend to regionalization of perinatal care, categorization of hospitals and transport services for neonatal health care. The literature alludes to both beneficial and deleterious effects of neonatal transport (T) but no controls such as a matched nontransport (NT) population have been utilized to date. The major goal of this study was to evaluate the effect of neonatal transport from Level I and II high risk less than or equal to 2500 gm. neonates (born in NYC in one calendar year, 1979) compared to a cohort nontransported population matched for hospital of birth, weight, race, sex and risk. All transported less than or equal to 2500 gm. from Level I and II (n = 328) were studied and a stratified random sample of the nontransported (NT) infants less than or equal to 2500 gm. from these same hospitals (n = 2042) was used for comparison. The principle outcome variable was survival. The major conclusion of this study is that in Level I and II hospitals the transport group had a significantly increased survival in infants who were sick (Apgar less than 6) compared to cohorted nontransported controls. Interhospital differences in survival were noted among Level I and II but not seen in the subdivisions of (A) and (B) hospitals.

Bilirubin in cerebrospinal fluid: an indicator of blood-brain barrier disruption in asphyxiated rats.

To evaluate the relationship of serum cerebrospinal fluid (CSF) and brain total bilirubin levels in asphyxia, an experiment was designed with 5 to 6-week-old Sprague-Dawley rats. The rats were randomized into control and experimental groups. All rats received intravenously 30 mg/kg of bilirubin. Four hours later the experimental group was asphyxiated. Forty-eight hours after asphyxiation, the bilirubin concentrations in blood, CSF, and brain were measured in both study groups. Mean CSF and brain bilirubin levels were significantly higher in the experimental compared to the control group; however, mean serum bilirubin levels were not different. Moreover, in the experimental group a significant correlation existed between CSF and brain bilirubin concentrations. In conclusion, an asphyxiatic insult resulted in disruption of both the blood-brain and the blood-CSF barriers.

Postnatal overestimation of gestational age in preterm infants.

In a study involving 25 preterm infants, obstetric clinical age (standard gestational age) was determined by history, physical examination, and ultrasonographic evaluation. Postnatally, these infants were then evaluated using the Dubowitz Scoring System (DSS) for gestational age assessment. The DSS, as administered by us, significantly overestimated gestational age compared with the standard gestational age (mean +/- 1 SD: 34.2 +/- 2.9 vs 32.5 +/- 3.9 weeks, respectively) in preterm infants. To illustrate, the gestational ages of 13 newborns (52%) in the total study group were each overestimated by more than two weeks. This percentage increased to 75% among the 16 infants whose gestational ages were less than 34 weeks (by standard gestational age). When the standard gestational age was underestimated by the DSS, this difference never exceeded two weeks. These findings suggest that the present system of postnatal assessment of gestational age in preterm infants needs further investigation.

Neonatal stabilization score. A quantitative method of auditing medical care in transported newborns weighing less than 1,000 g at birth.

A reduction in newborn (NB) mortality is contingent on efforts of NB stabilization. The authors attempted to quantify stabilization into a score, the neonatal stabilization score (NSS) that correlates with outcome. The population for the study comprised 192 transported NBs who weighed less than 1,000 g at birth moved from level 1 hospitals in New York City during 5 years, 1977-1981. The NSS score was based on five components: vital signs, laboratory investigations, respiratory support, I.V. fluid administration, and specific managements. Each was rated 0, 1, or 2. A maximum score of 10 indicated excellent stabilization. Analyses for the validity and reliability of the NSS included the Mantel-Haenszel test (which controlled for birth weight and Apgar) and measurement of interrater agreement "k" (kappa statistic). Mortality rates were lower in those with higher NSS and odds of death were 2.39 times greater in NB with low NSS (chi 2 = 5.16; P less than 0.025). The calculated index of agreement k on 16 charts represented an excellent agreement beyond chance (k = 0.76, P less than 0.01).

The effects of steroids on respiratory tolerance and somatic growth in gender-specific asphyxiated newborn rats.

Gender-specific newborn rats were randomized into two treatment groups: experimental (received steroid) and control (administered normal saline). Steroid treatment was initiated on 2nd day of life. Hydrocortisone sodium succinate at 10 mg/kg was administered intraperitoneally every 12 hours for four doses. On 3rd day of life, after the last dosage, all rats were asphyxiated once in a standardized manner. Steroids had no effect in improving respiratory tolerance. The experimental group in both genders, but more predominantly in females, gained less body weight compared to control littermates. However, no differences in somatic growth was detected between genders. This finding in newborn rats is in contrast to older rats where males are reported to be less resistant to the growth retarding effects of steroids.

The adverse effects of high oral osmolal mixtures in neonates. A review and a study of the osmolality of calcium preparations.

In both animals and humans, there are numerous clinical, physiologic, and morphologic alterations that occur when hypertonic solutions are introduced into the alimentary tract. The most serious adverse effect observed in the human infant is necrotizing enterocolitis. A short in vitro study analyzing osmolalities of drug-formula mixtures at various dilutions, conducted by the authors, showed that an unacceptable degree of high osmolality may be achieved in the preparation of common medications used in newborn nurseries. Although review of the literature confirms that, in general, the osmolalities of mixtures fed to newborns should not exceed 460 mOsm/kg H2O, lower levels would be preferable in ill and low birth weight newborns. When possible, consideration should be given to the use of parenteral medication for the critically ill neonate. Ideally, the osmolalities of mixtures fed to newborns should be measured if they are not known or cannot be calculated.

Impact of intermittent prolonged asphyxia in rat sucklings on growth and development.

Each of four litters of newborn rats was categorized first by sex and then within each litter, each sex-specific group was randomized into three treatment groups: an experimental (asphyxiated on 4 consecutive days from birth), a partial control (asphyxiated once on the fourth day of life), and a control group (never asphyxiated). Asphyxiation was carried out by enclosing pups individually in air tight fixed volume jars until they attained 30 second apnea. Weight and physical and reflex development of the rat pups were assessed daily. The data was analyzed by using ANOVA and ANCOVA to adjust for birth weight.