Variability of plasma cortisol levels in extremely low birth weight infants.

Cortisol is secreted by children and adults in a pulsatile pattern of 15-30 peaks and nadirs each day with a circadian rhythm. Newborns are known to lack the circadian pattern, leading to uncertainty about the appropriate time for blood sampling for assessment of adrenal function. Because extremely low birth weight (ELBW) infants may manifest signs of adrenal insufficiency, knowledge of the pattern of cortisol levels is necessary to guide the appropriate timing of blood sampling. To define the pattern of plasma cortisol levels in 14 ELBW infants, we obtained blood specimens every 20 min over a 6-h period at 4-6 days of life. Although cortisol levels in the 14 infants ranged from 2.0-54.5 micrograms/dL, each infant's cortisol levels varied little from his or her own mean cortisol level. The SDs calculated from each infant's mean cortisol level were small, ranging from 0.37-4.12 micrograms/dL. Cluster analysis was applied to the data; only 0.6 cortisol pulses/infant 6-h period were detected. Each infant's plasma cortisol levels were plotted against time, and regression analysis was performed. The slopes of the resulting lines of regression ranged from -0.0284 to 0.0221. Our data indicate that ELBW infants show little variability in their plasma cortisol levels over time; therefore, a single random measurement provides an adequate reflection of the adrenal status of the ELBW infant.

Subgaleal hematoma: the need for increased awareness of risk.

Subgaleal hematoma, also known as subaponeurotic hemorrhage, is a serious complication of birth that is associated with vacuum-assisted delivery. Despite a high rate of mortality associated with subgaleal hematoma, it has received relatively little attention in the medical literature. Lack of awareness may lead to delayed diagnosis and serious consequences for infants. This paper is a report of six cases and a literature review. Prevention and early recognition and treatment of the condition can occur only with increased practitioner awareness of this entity.

Transient myeloproliferative disorder of the Down type in the normal newborn.

Two infants with congenital nonlymphoblastic leukemia were discovered to have mosaicism for trisomy 21. Both infants achieved durable spontaneous remissions. Trisomy was apparently restricted to the leukemic clone and could be detected in neither phytohemagglutinin-stimulated peripheral blood cells or bone marrow in either patient nor in myeloid progenitor cells from the second patient after resolution of the transient myeloproliferative disorder. We conclude that spontaneous remission of congenital leukemia is not confined to infants with partial or complete systemic trisomy 21 but can occur in genetically normal newborns whose leukemic cells contain a third chromosome 21.

Nutritional balance studies of VLBW infants fed their mothers' milk fortified with a liquid human milk fortifier.

This article reports the results of a study designed to compare human milk fortified with a liquid human milk fortifier to a preterm infant formula by analyzing the metabolic balances of certain nutrients when these milks are fed to premature infants. Ten very low birth weight (VLBW) infants were studied during 4-day equilibration periods, then 4-day metabolic balances of N, fat, Ca and P, while each consumed a 1:1 mixture of a pool of its own mother's milk and the liquid human milk fortifier (HM/LF). For comparison, another 10 VLBW infants were studied in similar fashion while consuming the preterm infant formula (PF). Percent nitrogen retentions were 77 +/- 4% (+SD) and 79 +/- 4%, and fat absorptions were 94 +/- 7% and 92 +/- 5% in the HM/LF and PF groups, respectively, and did not differ between the groups. Calcium retention was 86 +/- 21 mg/kg/day (51 +/- 12%) in the HM/LF group and 104 +/- 43 mg/kg/day (45 +/- 19%) in the PF group. The percent Ca retentions did not differ. Phosphorus retentions were 56 +/- 7 mg/kg/day (67 +/- 9%) and 77 +/- 18 mg/kg/day (61 +/- 14%) in the HM/LF and PF groups, respectively. Increases in weight, length, and occipitofrontal circumference (OFC) were similar and normal in both groups. We conclude that VLBW infants fed the HM/LF, mixed 1:1 with their mothers' milk, had rates of absorption and retention of Ca, P, N, and fat similar to rates found in the concurrent study of VLBW infants fed a commercially available PF.

Prolonged inactive phases during the discontinuous pattern of prematurity in the electroencephalogram of very-low-birthweight infants.

A consecutive cohort of 46 very-low-birthweight infants, who had routine electroencephalograms (EEGs) while in the neonatal intensive care unit, were studied. Two infants were lost to follow-up and were excluded, leaving a study population of 44 infants. Their mean birthweight was 945 +/- 166 g, gestation 27.1 +/- 1.7 weeks. Thirteen infants died before discharge. The remaining 31 had a mean corrected age of 26.1 +/- 8.7 months at the time of the last visit. Three groups were distinguished: normal survivors, handicapped survivors and non-survivors. The longest inactive phase encountered in the discontinuous EEG was the yardstick of the study with 3 subdivisions: less than 20 sec. 20-29 sec and equal to or more than 30 sec. The data showed a relative increase in poor outcome with increasing duration of inactivity (P less than 0.05) and, conversely, a favorable outcome with the absence of 20 sec or longer inactivity (P less than 0.001). All infants received therapeutic doses of phenobarbital during the early part of their illness which could have affected their EEG. Mean phenobarbital levels, obtained close to the time of the EEG, however, did not differ significantly and failed to show a significant relationship between the duration of the inactive phase and drug level observed. Inactive phases greater than or equal to 30 sec were more common (P less than 0.01) in infants with intraventricular hemorrhage. We conclude: although full recovery and normal outcome have been documented, prolonged isoelectric phases beyond 30 sec are more common in infants with fatal outcome.

Insulin infusion with parenteral nutrition in extremely low birth weight infants with hyperglycemia.

From Nov. 7, 1983, to Nov. 6, 1986, all infants with birth weight less than or equal to 1000 gm admitted to Oregon Health Sciences University who had persistent hyperglycemia and glycosuria were treated with graded insulin infusion while energy intake was increased to at least 100 kcal/kg/day (419 kilojoules/kg/day). The records of these infants were reviewed to define the clinical characteristics of infants likely to develop hyperglycemia and to see whether insulin administration would allow goals for energy intake to be met. There were 76 surviving infants; 34 received insulin and 42 did not. Treated infants were smaller (767 +/- 161 vs 872 +/- 98 gm; p = 0.0004), were more immature (26.8 +/- 1.4 vs 27.7 +/- 2.0 weeks; p = 0.0115), and required mechanical ventilation longer (28 +/- 19 vs 17 +/- 15 days; p = 0.0196). There were no significant differences between the groups at 3, 7, 10, or 14 days for intravenously administered glucose or for total nonprotein energy intake at 3, 7, 10, 14, 28, or 56 days. Treated infants achieved an intake of 100 kcal/kg/day (419 kilojoules/kg/day) at 15 +/- 8 vs 17 +/- 11 days and regained birth weight at 12 +/- 6 vs 13 +/- 6 days (NS). There was no difference in percent change from birth weight at 7, 14, 28, or 56 days. Treated infants had a glucose concentration of 195 +/- 60 mg/dl (10.8 +/- 3.3 mmol/L) while receiving 7.9 +/- 3.0 mg/kg/min (43 +/- 17 mumol/kg/min) of glucose at the start of insulin infusion on days 1 to 14. Insulin was given for 1 to 58 days. The initial dose was 40 to 100 mU/gm of dextrose infused (57 to 142 nmol/mol) and then gradually decreased. Less than 0.5% of blood glucose values were 25 to 40 mg/dl (1.4 to 2.2 mmol/L). We conclude that insulin infusion improves glucose tolerance in extremely low birth weight infants and allows hyperglycemic infants to achieve adequate energy intake similar to that of infants who do not become hyperglycemic.

Outcome for fetus with ascites and cytomegalovirus infection.

The prenatal and neonatal course of a fetus with cytomegalovirus infection and ascites found on ultrasonographic examination at 27 weeks' gestation is reported. The ascites resolved within 4 weeks and the neonate had evidence only of mild congenital cytomegalovirus infection at birth. The factors predictive of the long-term outcome for an infant with congenital cytomegalovirus infection are reviewed. In this case, the finding that signs of significant disease in the fetus do not necessarily correlate with signs of severe congenital infection in the neonate is reported. It is suggested that prospective data are needed to aid in prediction of the course of fetal cytomegalovirus infection.

Benzyl alcohol toxicity: impact on mortality and intraventricular hemorrhage among very low birth weight infants.

Benzyl alcohol preservative in intravascular flush solutions has been reported to cause neurologic deterioration and death in very low birth weight infants. Following the widespread discontinuation of the use of such solutions in newborns, scattered reports of decreased mortality and decreased incidence of intraventricular hemorrhage among small premature infants appeared in the pediatric literature. To better assess the true impact of benzyl alcohol toxicity in this group of infants, we undertook a detailed review of the medical records of all babies less than 1,250 g birth weight admitted to our neonatal intensive care unit for 13 months before and 13 months after the use of solutions containing benzyl alcohol was stopped. Significant decreases were found in both mortality rate (from 80.7% to 45.7%) and incidence of grade III/IV intraventricular hemorrhage (from 46% to 19%) among infants less than 1,000 g birth weight who did not receive the preservative compared with those who did. No significant changes were found in several other prenatal factors that could have contributed to this improvement in survival. We conclude that benzyl alcohol toxicity contributed significantly to both mortality and the occurrence of major intraventricular hemorrhage among infants weighing less than 1,000 g at birth and that solutions containing benzyl alcohol should never again be used in the care of such infants.

Benzyl alcohol toxicity: impact on neurologic handicaps among surviving very low birth weight infants.

Benzyl alcohol preservative in solutions used to flush intravascular catheters has been linked with increased mortality and incidence of intraventricular hemorrhage in small preterm infants. This study evaluated the outcome of surviving very low birth weight infants exposed to benzyl alcohol while in our neonatal intensive care unit. Surviving infants, less than 1,250 g birth weight, admitted during the 12 months prior to discontinuation of benzyl alcohol (period I), were compared with those infants admitted during the 12 months after discontinuation of benzyl alcohol (period II). Survivors were enrolled in a follow-up program. Results of the study demonstrated that infants from period II had fewer neurologic handicaps. The incidence of cerebral palsy decreased from 50% to 2.4% (P less than .001), and the presence of cerebral palsy and developmental delay combined decreased from 53.9% to 11.9% (P less than .001). Several factors other than benzyl alcohol exposure were examined for their importance on outcome but were found not to be related to it. It is concluded that the dramatic improvement in outcome could be the result of discontinuation of benzyl alcohol.

Serum vitamin E levels in very low-birth weight infants receiving vitamin E in parenteral nutrition solutions.

Serum vitamin E levels were measured in 17 very low-birth weight infants in the first 2 wk of life, before and after the institution of intravenous vitamin E supplementation in a dosage of 4.5 mg/day, as a component of MVI Pediatric multivitamin preparation. Serum vitamin E levels were 0.22 +/- 0.16 (SD) mg/dl before supplementation, and rose to 2.55 +/- 0.65 (SD) mg/dl in nine infants more than 899 g birth weight, and rose to 3.68 +/- 0.70 (SD) mg/dl in six infants less than 900 g at birth. These postsupplementation serum vitamin E levels are in the range in which a reduction of incidence or severity of retinopathy of prematurity and intraventricular cerebral hemorrhage has been reported by others. No toxic effects of the preparation or of the increased vitamin E levels were found.

Selenium and vitamin E sufficiency in premature infants requiring total parenteral nutrition.

A randomized prospective study of LBW infants was undertaken to evaluate the effect of parenteral lipid infusions upon their antioxidant systems. Ten babies received a parenteral nutrition regimen with lipid emulsion, and ten received a regimen without lipid. Although the addition of lipid emulsion to the total parenteral nutrition regimen led to a rise in vitamin E levels, the selenium levels fell in both groups. Neither group showed evidence of deficient antioxidant systems by the peroxide hemolysis test or thiobarbituric acid test. There did not seem to be any adverse effect of the lipid infusion upon the clinical course of the infants except for hyperlipidemia. There was a better weight gain in infants receiving lipid.

Growth graphs for the clinical assessment of infants of varying gestational age.

Two graphs are presented showing means and 1 and 2 SD for growth in weight, length, and head circumference: (1) a fetal-infant graph with lines of growth from 26 weeks of gestational age until one year of age after ""term'' has been reached: and (2) a similarly constructed graph for children ages one through ten years. The standards of growth were obtained from published data in which the subjects received optimal health care. The graphs allow comparisons of infants of varying gestational age with standards for that age. Normal and abnormal deviations in growth are easily identified. Some examples of common variations in physical growth are described.