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OBJECTIVE: To provide population based data on the treatment requirements of infants with rhesus isoimmunisation. SETTING: Twenty nine hospitals in South Thames in which 81 119 deliveries occurred between February 1999 and January 2000. DESIGN: Every month, a clinician identified in each of the hospitals sent back a postcard indicating whether or not an infant with RhD had required treatment in their institution. Antenatal and postnatal information was then requested from all those who gave positive responses. MAIN OUTCOME MEASURES: Requirement for postnatal treatment for rhesus isoimmunisation. RESULTS: During the one year study period, only 26 infants required treatment for rhesus isoimmunisation. The median duration of phototherapy of the 26 infants was five days (range 1-12). Seven infants required at least one exchange transfusion (two required two exchange transfusions), and seven infants received one "top up" transfusion. None received erythropoietin and no infant died. CONCLUSION: The results suggest that few infants require treatment for rhesus isoimmunisation.

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BACKGROUND: It has previously been shown that, in preterm babies, routine sodium supplementation from 24 hours after birth is associated with increased risk of oxygen dependency and persistent expansion of the extracellular compartment. OBJECTIVE: To explore whether this is mediated by a delayed fall in pulmonary artery pressure (PAP). Postnatal changes in PAP, estimated as the ratio of time to peak velocity to right ventricular ejection time, corrected for heart rate (TPV:RVET(c)), were compared in preterm infants who received routine sodium supplements that were either early or delayed. METHODS: Infants were randomised, stratified according to sex and gestation, to receive a sodium intake of 4 mmol/kg/day starting either from 24 hours after birth or when a weight loss of 6% of birth weight was achieved. Echocardiographic assessment was made on the day of delivery (day 0), and on days 1, 2, 7, and 14. Babies with congenital heart disease were excluded. RESULTS: There was no difference between the two groups in TPV:RVET(c) measured sequentially after birth. On within group testing, when compared with values at birth, the ratio was higher by day 3 in the early supplemented group, suggesting a more rapid fall in PAP compared with the late supplemented group, in whom a significant fall did not occur until day 14. CONCLUSIONS: The timing of sodium supplementation after preterm birth does not appear to affect the rate of fall in PAP as measured by the TPV:RVET(c) ratio. The previous observation linking routine sodium supplementation from 24 hours after birth with increased risk of continuing oxygen requirement therefore does not appear to be mediated by a delayed fall in PAP. Instead, the increased risk of continuing oxygen requirement is likely to be a direct consequence of persistent expansion of the extracellular compartment and increased pulmonary interstitial fluid, resulting from a sodium intake that exceeded sodium excretory capacity. This adds further weight to the view that clinical management, in this case the timing of routine sodium supplementation, should be individually tailored and delayed until the onset of postnatal extracellular volume contraction, marked clinically by weight loss.

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An infant with symptomatic congenital Cytomegalovirus infection is reported. After the detection of abnormalities on cranial ultrasound scanning, magnetic resonance imaging of the brain revealed a complete absence of corpus callosum with a midline anterior tubulonodular lipoma. A proposed causative link between early in utero Cytomegalovirus infection and lipoma with agenesis of corpus callosum is discussed.

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Following birth there is a contraction in the extracellular compartment, marked clinically by natriuresis, diuresis and weight loss. It is uncertain how these postnatal phenomena, which suggest an interrelationship with cardiopulmonary adaptation, are brought about. The aim of this study was to evaluate the temporal relationship between alterations in circulating atrial natriuretic peptide (ANP), respiratory status, sodium excretion and extracellular fluid volume (ECFV) in preterm babies, in the first days after birth. Eighteen male infants below 34 weeks gestational age were studied longitudinally, measuring urine output, sodium balance, arterial-alveolar oxygen ratio and circulating ANP. Daily changes in ECFV were assessed by endogenous chloride balance, following baseline measurement of bromide space. There was a clear period of improvement in respiratory function in 15 babies and in these there was a highly significant elevation in circulating ANP, either immediately prior to, or during, the period of improvement. In three infants there was no definable period of respiratory improvement. In four babies, two of whom had very mild respiratory distress, there was an immediate decline in ECFV after birth, in contrast to the remaining 14 infants, in whom there was an initial increase. This study demonstrates that there is a temporal relationship between improvement in respiratory function and an acute elevation in circulating ANP. Babies with respiratory distress syndrome are at risk of initial expansion of the extracellular compartment after birth. This is likely to increase morbidity. These observations are of relevance with regard to the clinical management of newborns with respiratory distress syndrome.

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BACKGROUND: Preterm birth is often associated with impaired growth. Small for gestational age status confers additional risk. AIM: To determine the body water content of appropriately grown (AGA) and small for gestational age (SGA) preterm infants in order to provide a baseline for longitudinal studies of growth after preterm birth. METHODS: All infants born at the Hammersmith and Queen Charlotte's Hospitals between 25 and 30 weeks gestational age were eligible for entry into the study. Informed parental consent was obtained as soon after delivery as possible, after which the extracellular fluid content was determined by bromide dilution and total body water by H(2)(18)O dilution. RESULTS: Forty two preterm infants were studied. SGA infants had a significantly higher body water content than AGA infants (906 (833-954) and 844 (637-958) ml/kg respectively; median (range); p = 0.019). There were no differences in extracellular and intracellular fluid volumes, nor in the ratio of extracellular to intracellular fluid. Estimates of relative adiposity suggest a body fat content of about 7% in AGA infants, assuming negligible fat content in SGA infants and lean body tissue hydration to be equivalent in the two groups. CONCLUSIONS: Novel values for the body water composition of the SGA preterm infant at 25-30 weeks gestation are presented. The data do not support the view that SGA infants have extracellular dehydration, nor is their regulation of body water impaired.

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AIM: To compare the effects of early against delayed sodium supplementation on oxygen dependency and body weight, in preterm infants of 25-30 weeks of gestational age. METHODS: Infants were stratified by gender and gestation and randomly assigned to receive a sodium intake of 4 mmol/kg/day starting on either the second day after birth or when weight loss of 6% of birthweight was achieved. Daily sodium intake, serum sodium concentration, total fluid intake, energy intake, clinical risk index for babies (CRIB) score and duration of ventilatory support and additional oxygen therapy were recorded. Infants were weighed daily. Weights at 36 weeks and six months of postmenstrual age were also recorded. RESULTS: Twenty four infants received early, and 22 delayed, sodium supplementation. There were no significant differences in total fluid and energy intake between the two groups. There was a significant difference in oxygen requirement at the end of the first week, with 9% of the early group in air in contrast to 35% of the delayed group (difference 26%, 95% confidence interval 2, 50). At 28 days after birth the proportions were 18% of the early group and 40% of the delayed group (difference 22%, 95% CI -5, 49). Proportional hazards modelling showed early sodium supplementation and lower birthweight to be significantly associated with increased risk of continuing oxygen requirement. The delayed sodium group had a greater maximum weight loss (delayed 16.1%; early 11.4%, p=0.02), but there were no significant differences in time to maximum weight loss, time to regain birthweight, and weight at 36 weeks and 6 months of postmenstrual age. CONCLUSION: In infants below 30 weeks of gestation, delaying sodium supplementation until at least 6% of birthweight is lost has a beneficial effect on the risk of continuing oxygen requirement and does not compromise growth.

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AIMS: To compare the effects of early and delayed sodium supplementation on body composition and body water compartments during the first two weeks of postnatal life. METHODS: Preterm infants of 25-30 weeks' gestation were stratified and randomly assigned according to gender and gestational age, to receive a sodium intake of 4 mmol/kg/day beginning either on the second day after birth or when weight loss of 6% of birthweight had been achieved. Daily sodium intake, total fluid intake, energy intake, urine volume, and urinary sodium excretion were recorded. Total body water was measured by H(2)(18)O dilution on days 1, 7, and 14, and extracellular fluid volume by sodium bromide dilution on days 1 and 14. RESULTS: Twenty four infants received early, and 22 delayed, sodium supplementation. There were no significant differences between the groups in body water compartments on day 1. In the delayed group, but not the early group, there was a significant loss of total body water during the first week (delayed -44 ml/kg, p=0. 048; early 6 ml/kg, p=0.970). By day 14 the delayed, but not the early group, also had a significant reduction in extracellular fluid volume (delayed -53 ml/kg, p=0.01; early -37 ml/kg, p=0.2). These changes resulted in a significant alteration in body composition at the end of the first week (total body weight: delayed 791 ml/kg; early 849 ml/kg, p=0.013). By day 14 there were once again no significant differences in body composition between the two groups. CONCLUSIONS: Body composition after preterm birth is influenced by the timing of introduction of routine sodium supplements. Early sodium supplementation can delay the physiological loss of body water that is part of normal postnatal adaptation. This is likely to be of particular relevance to babies with respiratory distress syndrome. A tailored approach to clinical management, delaying the introduction of routine sodium supplements until there has been postnatal loss of body water, is recommended.

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A case of ingestion of oil of cloves is presented, which resulted in coma, fits, a coagulopathy, and acute liver damage. This is not unlike the syndrome produced in the late stages of a substantial paracetamol overdose, and a similar treatment regimen is proposed.

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