The significance of recurrent lung opacities in neonates on surfactant treatment for respiratory distress syndrome.

PURPOSE: To determine the significance of recurrent opacities in chest radiographs of neonates on surfactant therapy for respiratory distress syndrome (RDS) after an initial period of improvement. MATERIALS AND METHODS: Serial pre-and post-surfactant chest radiographs on 94 preterm infants with RDS were analyzed and the pattern of chest radiographic response was classified as (a) clear, (b) recurrent opacities, and (c) no response. Their clinical characteristics were also recorded. RESULTS: In 34 infants the RDS changes cleared within 3 days. 31 infants developed lung opacities within 10 days after an initial period of improvement. Twenty-nine infants failed to respond to the surfactant. The corresponding mean birth weights for the three groups were 1.74, 1.19, and 0.76 kg and the mean gestation ages 32.6, 27.7, and 25.4 weeks. The incidence of bronchopulmonary dysplasia (BPD) was highest among the slumping infants (72% vs. 50% in no responders, P<0.001) CONCLUSIONS: The pattern of chest radiographic response is primarily affected by gestation age and birth weight. Recurrent lung opacity after an initial positive response to surfactant therapy may be caused by such factors as edema from barotrauma and patent ductus arteriosus. Infants with intraventricular hemorrhage may demonstrate neurogenic edema. Other contributory factors include pneumonia and abnormal consumption of surfactant. Recurrent lung opacities after surfactant may be a predictor of chronic lung disease in the preterm infant.

CT and MRI characteristics of intracranial hemorrhage complicating breech and vacuum delivery.

The CT/MRI brain findings and sequelae of intracranial hemorrhage resulting from traumatic breech and vacuum delivery of 16 term newborn infants are presented. Eleven infants were vacuum extracted, while the remaining five infants were delivered breech. Except for three breech-delivered infants who had intraventricular hemorrhage, the location and nature of hemorrhage were similar in both groups. Nine of the 11 vacuum-extracted babies showed complete resolution of hemorrhage on follow-up examination. None of the breech cases had a normal outcome. All five of the latter group had hydrocephalus, and one case each demonstrated porencephaly and encephalomalacia.

Clinical significance of resolution of chest X-ray findings in HIV-infected children with lymphocytic interstitial pneumonitis (LIP).

Lymphocytic interstitial pneumonitis (LIP) in HIV-infected children is generally associated with better prognosis as compared with children with Pneumocystis carinii pneumonia (PCP). We prospectively studied 12 cases of HIV-infected children with LIP over a 4-year period in an effort to document one aspect of the natural history of this clinical entity. Severe CD4 lymphocytopenia was associated with complete resolution of the chest X-ray findings in five patients, one of whom died of disseminated Mycobacterium avium complex. A second patient developed rapid-onset subacute HIV encephalopathy at the time when the CD4-lymphocyte count declined from 589 to 39, and the lung findings resolved spontaneously. The resolution of the lung pathology may be the first indication of severe immune suppression and a warning of the increased risk for opportunistic infections. Therefore, in those settings where diagnostic laboratory facilities are not easily available, the resolution of the reticulonodular changes on chest radiographs is a poor prognostic sign in HIV-infected children with LIP.

Multiple herniae: a defect in the celomic mesoderm?

We report on a child with congenital bilateral cervical lung herniation with associated retrosternal (Morgagni), posterolateral (Bochdalek), esophageal hiatal, and inguinal herniae, and with multiple urinary bladder diverticuli. These multiple herniations may be secondary to a defect in the embryonic celomic mesoderm.

Cortical bone mass in Nigerian children: an anthropometric assessment.

Cortical bone mass was quantified in 1278 Nigerian children (695 males and 583 females) aged 3-16 years in a prospectively designed cross-sectional and longitudinal study. The total bone width (T) and medullary cavity width (M) were measured at the midshaft of the second metacarpal bone using a direct reading caliper. From the above measurements the cortical width (C), cortical area (CA), and percent cortical area (PCA) were calculated using the method of Garn et al. and showed a progressive increase of T, C, CA and PCA, reaching a plateau at 15 years. At all ages, the values for both T and M are higher in males than in females. On the other hand, and contrary to established normal values amongst both white and black Americans, between the ages of 9 and 15 the female values for C are higher than those for males. This difference is greatest at the age of 12 years (p < 0.001). The implication of this finding may be that during these years, African male children do not compensate for the increased endosteal resorption with a greater total cortical width (T), since the medullary width in females remains relatively constant over the years.

Post-extubation atelectasis in ventilated newborn infants.

Post-extubation atelectasis (PEA) constitutes the commonest cause of lung collapse in ventilated neonates. The clinical and radiological features of 47 ventilated infants who developed PEA within 24 h of extubation are reported. Three main radiographic patterns of atelectasis were identified: (1) transient unilobar collapse resolving within 12 h of extubation (19 cases), (2) multilobar atelectasis developing over a 48-h period (18 cases), and (3) progressive atelectasis resulting in complete collapse of a whole lung. A similar number of ventilated infants without PEA served as controls. We found a significant association between the incidence of PEA and multiple intubation (P < 0.02), presence of patent ductus arteriosus (P < 0.001) and neonatal sepsis (P < 0.05). Prophylactic physiotherapy is recommended for ventilated infants, particularly those with the above risk factors.

The widened frontal subarachnoid space. A CT comparative study between macrocephalic, microcephalic, and normocephalic infants and children.

The computed tomographic scans of the heads of 67 infants and children with frontal subarachnoid space widening seen during a 5-year period were retrospectively studied. Only 22.3% of patients had macrocephaly. Comparison of the clinical and radiologic characteristics of subarachnoid widening in macrocephalic children and in normocephalic or microcephalic children showed no significant differences. It is concluded that undue emphasis has been laid on the association between this radiologic sign and macrocephaly. Widening of the subarachnoid space in children may be a variation of normal development of brain whereby there is a transient accumulation of cerebrospinal fluid in the frontal region. The term "external hydrocephalus" may therefore be inappropriate in the absence of significant ventricular widening and clinical signs of raised intracranial pressure.

Neonatal phrenic nerve paralysis resulting from intercostal drainage of pneumothorax.

Four cases of phrenic nerve paralysis complicating chest tube placement in the newborn for pneumothorax are presented. This complication is related to abnormal location of the medial end of the chest tube. It is suggested that on the frontal chest radiograph, the medial end of the chest tube should be no less than 1 cm from the spine.

Normal values for metacarpal and phalangeal lengths in Nigerian children.

Metacarpal and phalangeal lengths were measured on 1290 hand radiographs of Nigerian children, aged 3-16 years. The radiographs were obtained during a combined cross-sectional and longitudinal study of growth and development. There is a linear increase in tubular bone length with age in both sexes. The girls have higher values for all the bones up to the age of 13 years when the boys overtake them. Comparison of our data with those from North American children shows that the values amongst Nigerian children are higher than White, Black American and Mexican American children. Of particular note is the difference between Black American and Nigerian figures. It is postulated that the decreased metacarpophalangeal lengths in Black Americans compared with Nigerians may be due to 'gene dilution'.

Hilar enlargement in respiratory syncytial virus pneumonia.

The clinical and radiographic features of ten children with hilar enlargement in association with proven Respiratory Syncytial Virus (RSV) infection are described. Hilar enlargement was seen in 10/35 children with RSV infection, and was invariably unilateral and right sided. It is recommended that RSV pneumonia be considered in children with unilateral hilar enlargement if tuberculosis has been excluded, and the onset of disease is rapid.

Cardiothoracic ratio in Nigerian newborn infants.

Cardiothoracic ratio was calculated from measurements made on the frontal radiographs of 172 normal (appropriate for gestational age) Nigerian newborn infants. The normal ratio was compared with those of 30, 32 and 42 neonates with respiratory distress syndrome, birth asphyxia and parenchymal lung disease respectively. The ratio for normal neonates was 49.12%. It was however significantly increased in respiratory distress syndrome (51.18%) and asphyxia (50.81%). The cardiothoracic ratio values obtained in this study are lower than those in Caucasian newborn infants.

Gastric distension in neonatal necrotising enterocolitis.

Nine cases of neonatal necrotising enterocolitis with a combination of gastric distension, paucity of bowel gas and bowel wall oedema are presented. It is postulated that the gastric distension may either be a result of a temporary obstruction at the pyloric canal from oedema or a direct effect of bacterial toxins on ischaemic gastric mucosa. Six (66%) of the 9 infants were term and it is suggested that any newborn infant presenting with isolated gastric distension with bloody stools should be treated as a case of necrotising enterocolitis.

Tibial and fibular angles in homozygous sickle cell disease.

Measurements of the tibial and fibular angles made on ankle radiographs of 34 patients with sickle cell disease were compared with those of 36 normal Nigerians. Widening of the fibular angle, which is an indication of tibiotalar slant, was demonstrated in about 79% of sickle cell disease patients. By using fibular angle measurements as an objective method of assessing subtle tibiotalar slant, it is concluded that the incidence of this deformity is much higher among sickle cell disease patients than previously reported. The mean values of tibial and fibular angles in normal Nigerians are higher than has been reported amongst Caucasians.

Pneumatisation of the maxillary sinus in normal and symptomatic children.

The pattern of pneumatisation and normal width of the maxillary sinus in 191 Nigerian infants and children whose age range was 6 months to 14 years was determined. Fifty-four percent of children with no respiratory tract or sinus infection had an opaque maxillary sinus. A figure of 44.5% was obtained amongst children with suspected bronchopneumonia. Only 41.5% of suspected cases of sinusitis, acute and chronic middle ear disease had opaque sinuses. The highest rate of sinus opacity was seen in children under 2 years who were asymptomatic. The mean maximal width of the normally aerated sinus was 8.74 mm for children under 2 years, 16.5 mm for 3-6 years, 21.5 mm for 7-11 years and 25 mm for children 12 years and above. We conclude that maxillary sinus opacity in our experience is an unreliable index for the diagnosis of sinusitis in children.

Bone cortical mass in newborn infants: a comparison between standards in the femur and humerus.

The total bone width (T) and medullary width (M) of the humerus and femur of 216 and 138 Nigerian newborn infants, respectively, were measured in order to determine the normal standards for cortical bone mass in the newborn. The cortical width (C), cortical area (CA), and percentage cortical area (PCA) were calculated for each bone and correlated with gestational age and birth weight. In both the femur and humerus, the values of the cortical measurements were higher in males. The strongest correlation coefficients were obtained between T(0.84), C(0.79), and CA(0.84) and birth weight in the humerus. The correlation with gestational age was, however, similar in both bones. The values of humeral cortical width (C) obtained in this study is less than had been reported in North American white newborn infants. Cortical measurements of the humerus, which is invariably included in the newborn chest radiograph, is a more reliable method of evaluating the status of bone mineralisation than the femur.

Width of the presacral space in Nigerian adults.

The width of the presacral space and the thickness of the rectal valve were measured on lateral radiographs obtained during barium enema examinations performed on 182 Nigerian adult patients over a 5-year period (1980-1984). The mean width of the presacral space was 0.78 cm, the value in men being significantly higher than in women (p less than 0.01). Although these values are similar to those reported among Caucasians, a wider range of normal values was obtained in this study. There is also no significant difference between the mean value of the rectal valve thickness of 4.3 mm obtained in this study and that obtained from previous studies.

Bone and soft tissue components of the leg in infants with protein calorie malnutrition.

The measurements of muscle, fat and cortical thickness were made on leg radiographs of 40 kwashiorkhor infants and were compared with those of 32 normal infants. There is a significant decrease in muscle cylinder ratio, an index of the contribution of muscle to calf thickness in kwashiorkhor. The loss of bone cortex in kwashiorkhor is due mainly to failure of appositional growth. The muscle cylinder ratio in normal Nigerian infants is much higher than has been reported amongst Caucasians.

Symptomatic urinary tract infections in high-risk Nigerian newborn infants.

Thirty-nine high-risk newborn infants with proven urinary tract infections were studied and compared with 51 control infants. The remarkably low incidence of 0.82/1000 live births and the absence of radiological abnormalities of the urinary tract contrast with previous reports in the literature. Septicaemia and necrotizing enterocolitis were more frequently encountered in infants with urinary tract infection. Escherichia coli and klebsiella were the predominant pathogens isolated. The male preponderance to urinary tract infection is confirmed in this study. The overall mortality rate of 10.3% was closely associated with intercurrent problems.