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BACKGROUND: Recent cost-containment strategies suggest limiting screening neurosonograms to the second week of life in premature infants with lower gestational ages (< 30 weeks), birth weights (< 1250 g), or more complicated clinical courses. OBJECTIVE: To determine if such strategies reduce detection of cystic periventricular leukomalacia (cPVL) and persistent ventricular enlargement (pVE)--late sonographic abnormalities highly predictive of adverse neurodevelopment in preterm infants. METHODS: Timing, findings, and number of neurosonograms were reviewed for all survivors born at < or = 32 weeks' gestation at University Hospital, Denver, Colo., between January 1992 and June 1995. RESULTS: Of 236 surviving infants, 61 (26%) were never scanned, and 175 (74%) had a total of 432 scans. Only 106 infants (45%) had a neurosonogram on or after 28 days (timed to detect all cPVL/pVE). Eleven infants (4.7%) had cPVL, and 19 (8%) had pVE. Severity of clinical course did not predict development of cPVL, but was a better predictor of pVE. Initial neurosonograms were normal in 6/11 (55%) with cPVL and 5/19 (26%) with pVE. Screening declined from 86% of infants in 1992 (average 2.54 neurosonograms each), to 64% by 1994-1995 (average of 2.22 neurosonograms each). Infants > 30 weeks' gestation comprised 55 of 61 patients without any neurosonograms (90%), 4 of 11 patients with cPVL (36%), and 4 of 19 patients with pVE (21%). CONCLUSION: Screening neurosonography has declined from 1992 to 1995, particularly in larger premature infants (30-32 weeks' gestation) who remain at risk for cPVL and pVE. Clinical course or results of initial studies do not always predict the development of these late abnormalities. We recommend that one neurosonogram be done at > or = 4 weeks of age in all premature infants < or = 32 weeks' gestation, regardless of birth weight, clinical course, or results of prior studies. An earlier neurosonogram should be obtained for infants < 30 weeks' gestation in the second week of life to detect complications of intracranial hemorrhage.

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The issue of early newborn discharge has received widespread attention in both the lay press and the medical literature over the past few years, culminating in passage of Public Law 104-204, Title VI: The Newborns' and Mothers' Health Protection Act of 1996. This article reviews the road to passage of this legislation, including the historical trends and forces determining postpartum length of stay in the United States, the evolution of guidelines as put forth by official representative bodies such as the AAP, the current status of state and federal legislation, and the relationship between length of stay and follow-up practices. The status of newborn length of stay in other countries also is discussed.

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OBJECTIVE: To prospectively validate a previously reported scoring system for identifying the near-term infant at risk for the multiple organ system sequelae of acute perinatal asphyxia. STUDY DESIGN: Prospective observational study. SETTING: Three Denver teaching hospitals, each providing comprehensive obstetric care. SUBJECTS: Newborn infants of 36 weeks or more gestation. INTERVENTION: None. STATISTICAL ANALYSIS: Chi-squared analysis with Fisher's exact test. OUTCOME: Scores consisting of graded abnormalities in fetal heart rate monitoring, umbilical arterial base deficit, and 5-minute Apgar score were calculated by the research nurse after admission of the infant to the nursery (range of possible scores, 0 to 9). A second nurse, blinded to these data, prospectively followed the newborn's hospital course for multiple organ system morbidity. RESULTS: Three thousand two hundred thirty-eight newborns were studied; 366 required neonatal intensive care unit admission. Eleven newborns had a score > or = 6 (mean umbilical artery pH = 6.98, base deficit = 17.1 mEq/L). Morbidities in these 11 newborns included seizures (2), hypoxic-ischemic encephalopathy (5), respiratory distress (9), hypotension (7), renal dysfunction (9), hypoglycemia/hypocalcemia (4), and thrombocytopenia or disseminated intravascular coagulopathy (3). The odds ratio (OR) and 95% confidence interval (CI) for newborns admitted to the neonatal intensive care unit with a score > or = 6 for having multiple organ system morbidity, defined as three or more affected organ systems, was 38.5 (95% CI, 9.2 to 127.8). The scoring system showed a stronger relationship with multiple organ system morbidity than did isolated individual indicators commonly used to identify asphyxia calculated on the same subjects: for those with pH < 7.00, OR 24 (95% CI, 6.4 to 94.1); base deficit > or = 10 mEq/L, OR 4.5 (95% CI, 1.9 to 10.3), and 5-minute Apgar score < or = 3, OR 7.4 (95% CI, 1.3 to 38.1). CONCLUSION: This scoring system, encompassing both immediate intrapartum and postpartum measures and acid-base status proximate to the time of delivery, is useful for rapidly identifying the term and near-term newborn at risk for multiple organ system morbidity after acute perinatal asphyxia.

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Premature rupture of the membranes (PROM), membrane rupture before the onset of labor, occurs in 2% to 18% of pregnancies. The time from PROM to delivery (latency) is usually less than 48 hours in term pregnancy. Therefore, the risks of PROM at term are related to fetal distress, prolapsed cord, abruptio placenta, and rarely, infection. Preterm PROM (pPROM), PROM before 37 weeks' gestation, accounts for 20% to 40% of PROM, and the incidence is doubled in multiple gestations. The latency period in pPROM is inversely related to the gestational age thereby increasing the risks of oligohydramnios and infection in very premature infants and their mothers. Because pPROM is associated with 30% to 40% of premature births, pPROM is also responsible for the neonatal problems resulting from prematurity. This review examines the impact of PROM on the neonate including fetal distress, prematurity, infection, pulmonary hypoplasia, and restriction deformations.

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The spectrum of organisms responsible for lower respiratory tract infection in chronically ventilated neonates is poorly defined. During an 18-month period 63 infants with a respiratory deterioration defined as an increase in fractional inspired O2 concentration > or = 20% and/or mean airway pressure > or = 3 cm H2O were evaluated for pulmonary infection. These infants were compared with 58 stable control ventilated infants. Tracheal aspirates for culture and Gram stain were taken from both groups and were cultured for bacteria, viruses, Chlamydia trachomatis, Ureaplasma urealyticum and Mycoplasma hominis. In addition each infant had complete blood counts with differential and chest roentgenograms evaluated. Positive tracheal aspirates defined as a heavy growth of a single or two bacterial organisms, and/or any growth of virus, Chlamydia and U. urealyticum were found in 23 of 63 study patients and 20 of 58 controls (P > 0.05). The most frequent isolate in both groups was U. urealyticum. Chest radiographs were positive (new changes, particularly atelectasis and infiltrates) more frequently in the study group than in controls, but complete blood count and tracheal aspirate Gram-stained smears were not helpful in discerning colonization from infection. We conclude that positive tracheal aspirates occur with equal frequency among infants with a clinical suspicion of lower respiratory tract infection and in "well" controls. Chest roentgenogram may be a useful adjunctive test to discriminate between colonization and lower respiratory tract infection.

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Perinatal asphyxia remains a concern for physicians, patients, and attorneys. The history of concern for this condition is reviewed, and efforts in neonatal-perinatal medicine to identify at risk patients and prevent serious sequelae are discussed. A definition consistent with the American Academy of Pediatrics-American College of Obstetrics and Gynecology Guidelines for Perinatal Care, requiring multiple biochemical and clinical indices for asphyxia, is given.

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Group B streptococcus (GBS) is a common cause of early-onset sepsis in neonates. The most recent reviews describing incidence, diagnosis, treatment, and outcome evaluated data on patients from the early 1980s. To obtain current information about this disease, we retrospectively evaluated data on neonates with GBS early-onset sepsis from nine hospitals in the United States between Jan. 1, 1987, and Dec. 31, 1989. There were 245 infants with GBS bacteremia identified among 61,809 live births, resulting in an incidence of 0.32%. Ninety-six infants (39%) were preterm (less than 38 weeks of gestational age). Maternal risk factors for infected preterm and term infants were similar. Antibiotics were administered during parturition in 10% of infants with bacteremia. Mothers of preterm infants received antibiotics up to 48 hours before delivery; mothers of term infants received antibiotics less than 4 hours before delivery. All preterm infants with bacteremia had symptoms; 22% of term infants with bacteremia had no symptoms. Group B streptococcal meningitis was confirmed in 6.3% of infants. Although 86% survived, GBS sepsis increased the birth weight-specific mortality rate up to eightfold in preterm infants and more than 40-fold in term infants. Although the incidence of GBS early-onset sepsis is not changing, we speculate that the improved birth weight-specific survival rate and the changing clinical presentation are due to improved intrapartum and neonatal management.

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We retrospectively reviewed clinical and echocardiographic data on 10 newborns with erythroblastosis fetalis who were admitted to our nurseries between 1984 and 1988 and who required a double-volume exchange transfusion and neonatal intensive care. Echocardiograms were performed in the first 48 hours of life. In 5 patients, disproportionate septal hypertrophy was demonstrated; 1 additional patient had biventricular hypertrophy with a thickened septum but not disproportionate septal hypertrophy. The mean septal: left ventricular free-wall ratio for the group (n = 10) was 1.37. No correlation was apparent between the occurrence of disproportionate septal hypertrophy and newborn glucose, bilirubin, or hematocrit values. When analyzed separately, the 4 patients who did not receive intrauterine blood transfusions had a ratio of 1.73 +/- 0.21 (mean +/- SEM); this was significantly greater than the ratio in the 6 patients who were transfused in utero (1.13 +/- 0.24). In patients who underwent transfusions, there was no correlation between the number of transfusions and the septal:left ventricular ratio. This study reports a significant but previously unrecognized cardiac hypertrophy with disproportionate septal hypertrophy in patients with erythroblastosis fetalis. Our data suggest a sparing effect of intrauterine fetal transfusions. The mechanism by which these transfusions may affect the hypertrophic development of the myocardium remains to be determined.

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Transcutaneous collection of theophylline and its metabolite, caffeine, was undertaken in 33 preterm infants (2 to 89 days old) who were receiving routine theophylline therapy. Collection was done by means of a novel adhesive transcutaneous collection system. The transcutaneous collection system accumulated substances that migrated from the blood to the skin surface by trapping them in an activated charcoal-gel matrix. On one to three occasions, four transdermal collection systems were applied to the back or abdomen of each infant for 4 to 12 hours. During that time, blood samples were obtained for routine monitoring of plasma theophylline levels. Amounts of theophylline (95 +/- 198 ng) and caffeine (83 +/- 77 ng) in the transcutaneous collection system were significantly correlated with the respective average plasma drug concentration and postconceptional age (p less than 0.01). Skin reactions were limited to mild erythema. We concluded that theophylline and caffeine can be collected on the surface of the skin of preterm infants with a novel transcutaneous collection system. Amounts collected by means of the transcutaneous collection system correlated with plasma concentrations consistent with a diffusion process, but they were poor predictors of individual concentrations.

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Predicting immediate neonatal morbidity after perinatal asphyxia has been difficult. A review of asphyxiated neonates greater than or equal to 36 weeks' gestation admitted to The Children's Hospital Newborn Intensive Care Unit in 1983 was conducted to devise a scoring system that would rapidly predict organ dysfunction observed in the immediate neonatal period. Comparison of potential score components to morbidity by multiple regression analysis yielded significant association with abnormalities in fetal heart rate monitoring, the 5-minute Apgar score, and neonatal base deficit. A scoring system was devised whose sensitivity (93.8%) and specificity (81.3%) were more predictive than any of its individual components. Prospective analysis in a similar population in 1984 validated its ability to distinguish severe from moderate morbidity after asphyxia. Positive predictive value for the score in the combined study groups (n = 98) was 79% and the negative predictive value was 83%. The scoring system may offer a rapid and accurate prediction of organ dysfunction in the immediate neonatal period after asphyxia.

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Determination of appropriate theophylline maintenance doses in preterm infants is confounded by interpatient variability. This study evaluated the performance of an IBM PC computer program applying Bayesian regression before and during steady state in 37 preterm infants. Prior population estimates of clearance and distribution volume in preterm infants and Bayesian estimates of clearance and distribution volume based on one to three theophylline plasma concentrations were used to predict subsequent concentrations (drawn 1-17 days later). We assessed the accuracy and precision of the predictive performance of the Bayesian program with the mean prediction error and the mean absolute prediction error. The absolute prediction error (mean absolute error +/- SEM) significantly decreased with increasing feedback concentrations from 3.54 +/- 0.45 micrograms/ml (population estimates) to 2.74 +/- 0.42 (one feedback) and 2.02 +/- 0.35 micrograms/ml (two feedback concentrations). Mean prediction errors (+/- SEM) based on one to three feedbacks (-1.5 +/- 0.40 micrograms/ml) were significant improvements over population predictions (-2.63 +/- 0.72 micrograms/ml, p less than 0.05), although a small but significant average overprediction remained. Absolute prediction error was correlated with postconceptional and postnatal age when zero or one but not two feedback concentrations were available. Computer program predictions based on one measured feedback concentration were more accurate and precise than population-based predictions. Refinement of population parameters or two feedback concentrations further improved performance.

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UNLABELLED: To determine whether axillary temperature in an arm with a peripheral IV infusion (PIVI) is significantly different than in the arm without a PIVI in neonates. METHOD: Twenty-nine neonates ranging in Dubowitz gestational age from 27-42 weeks were selected from Level II and III nurseries. Each had a PIVI in place in an upper extremity. Right axillary, left axillary, and rectal temperatures were taken simultaneously. RESULTS: There was no significant difference between left and right axillary temperatures using a t-test. CONCLUSION: Either axilla may be used for temperature measurement regardless of PIVI placement.

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