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The pharmacokinetics of once-a-day netilmicin (4.5 mg/kg) was studied in 16 neonates, divided for analysis into three groups according to gestational age: group 1 >36 weeks (n=7); group II between 34-36 weeks (n=4); and group III <34 weeks (n=5). The serum netilmicin (mean +/- SD) 4h and 24h after the first dose were 4.7 +/- 0.8 and 0.8 +/- 0.5 mg/L; 4.9 +/- 0.8 and 1.9 +/-0.2 mg/L; 4.9 +/- 0.5 and 1.7 +/- 0.5 mg/L in groups I, II and III respectively. After the second dose, concentrations at 2, 4, 8, 16 and 24 h were 7.2 +/- 1.0, 5.0 +/- 0.8, 3.0 +/- 0.6, 1.7 +/- 0.4 and 0.9 +/- 0.2 mg/L (group I); 8.6 +/- 0.2, 6.1 +/- 0.5, 4.2 +/- 0.7, 2.6 +/- 0.1 and 1.4 +/- 0.4 mg (group II); 9.0 +/- 1.2, 6.3 +/- 0.9, 4.1 +/- 0.7, 2.6 +/- 0.5 and 1.7 +/- 0.3 mg/L (group III). There was a large degree of inter-patient variability in serum concentrations and serum half-life (t1/2), volume of distribution (VD), area-under-the-curve (AUC), relative serum clearance (Clp) such that these parameters could not be correlated to age or weight. Absolute serum clearance (L/h) was correlated with gestational age (r = 0.672, P <0.01). There was no statistically significant evidence of accumulation between the first and second doses for any patient group. One baby from each group II and group III had concentration >2 mg/L 24h after the first dose and one baby from group III had concentration >2 mg/L 24h after the second dose. There are no established correlations between serum netilmicin concentrations and efficacy or toxicity in neonates and keeping 24 h trough concentration below 2 mg/L with a once-a-day dose of 4.5 mg/L would have to be validated in terms of its clinical efficacy and potential toxicity in a neonatal population.

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AIMS: To evaluate the effect of L-carnitine supplementation (25 mg/kg/d) on the growth and incidence of hypoglycaemia in preterm infants. METHODS: A double blind, placebo controlled randomised trial, stratified for gestational age, was conducted of 86 preterm infants between 28 and 34 gestational weeks. The median gestational ages in the carnitine group and placebo groups were 30.7 weeks (range 28.0 to 33.6) and 31.4 weeks (range 28.0 to 33.9), respectively. The median birthweights were 1.557 kg (range 0.944 to 2.275) and 1.645 kg (range 0.885 to 2.545), respectively. RESULTS: Mean plasma free carnitine concentrations were below values for normal term infants in both groups on day 1 (carnitine group 44.8 mumol/l, placebo group 25.5 mumol/l) in the placebo group on day 7 (50.7 mumol/l), but in neither group on days 14 and 28. Total, free, and acylcarnitine concentrations were significantly increased in both urine and blood in the L-carnitine group. There was no significant difference between the placebo and carnitine supplemented groups in growth rate, as assessed by weight, length, skinfold thickness and head circumference measurements, or in the incidence of episodes of hypoglycaemia. CONCLUSION: The addition of carnitine as a nutritional supplement at a dose of 25 mg/kg/day did not improve growth in our group of preterm infants nor protect them from episodes of hypoglycaemia.

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There are few data to inform a decision to resuscitate babies who are unexpectedly stillborn. The outcome for 42 successfully resuscitated stillborn children, of whom 62% survived to be discharged home, is reported. Of the survivors, a poor outcome with severe disability was found in 23% (including one postneonatal death), equivocal outcome was found in 15% (two mild hypertonia; two with mild hemiplegia and no associated other disability) and 62% were free of any impairment at follow up 20 months to 8 years later. In 39 (93%) fetal problems had been identified and the resuscitation team was present at delivery. Poor outcome was associated with late return of heart beat, delayed respirations, neonatal acidaemia and early onset of seizures. Of the unexpected apparent stillbirths successfully resuscitated, 52% died or survived severely disabled, 10% had an equivocal outcome, but 36% survived apparently intact. Therefore, vigorous resuscitation is clearly indicated in these circumstances.

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A woman at 32 weeks' gestation with eclampsia was given 120 mg diazepam shortly before emergency caesarean section. The infant had persistent apnoea and required respiratory support. Spontaneous respiration began after intravenous flumazenil infusion was started. Diazepam and its active metabolites were assayed during and after 5 d of treatment with flumazenil.

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Neonatal pain response and adverse effects and maternal anxiety were assessed in 27 infants who were randomly allocated to venepuncture or heel stick. Pain was assessed by nurses using the Neonatal Infant Pain Scale (NIPS) and a three point scale for the mothers. NIPS scores were higher in the heel stick group compared with the venepuncture group. Maternal anxiety was higher before the procedure while perception of an infant's pain was lower in the venepuncture group compared with the heel stick group. Venepuncture is less painful than heel stick in newborn infants undergoing routine blood sampling.

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The pharmacokinetics of once a day netilmicin (6 mg/kg) was studied in 21 neonates. The babies were divided into three groups according to gestational age: group I aged > 36 weeks; group II between 34-36 weeks and group III < 34 weeks. Serum concentrations were variable between patients and the concentration 24 h after the first dose ranged from 0.8 to 3.8 mg/L with only two babies having concentrations of < 1 mg/L while seven had concentrations of > 2 mg/L. There were also large patient-to-patient variations in serum half-life, volume of distribution, area under the curve and relative plasma clearance such that these parameters could not be correlated to gestational age or weight. Absolute plasma clearance was correlated with both gestational age and weight. There was evidence of accumulation between the first and second dose for all three patient groups and for patients of gestational age < 34 weeks (group III) these observations were statistically significant. A netilmicin dosage of 4.5 mg/kg once a day may be more suitable for all neonates supported by assay of serum concentrations.

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An infant with the oculo-auriculo-vertebral (OAV) spectrum is described with the previously unreported association of rectal agenesis with recto-urethral fistula. The patient died at the age of 14 weeks from respiratory obstruction. Autopsy revealed the cause of death to be tracheal compression from a pulmonary artery sling. Previous reports of vascular rings within the OAV spectrum are reviewed, and it is concluded that these malformations are an uncommon, but clinically important, complication of the disorder.

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OBJECTIVE: To assess the value of the second neonatal examination as a medical surveillance procedure. DESIGN: Prospective survey of routine neonatal examinations and the abnormalities identified during 8 March-30 June 1988. SETTING: Maternity unit with an annual birth rate of 5700. SUBJECTS: For first neonatal examination: 1795 babies born in the unit during the 115 day observation period. For second routine examination: 1747 babies (97.3%) discharged from postnatal ward. MAIN OUTCOME MEASURES: Missed abnormalities (present but not previously noted); minor abnormalities (superficial infection or trivial or transient abnormalities not requiring intervention); and important abnormalities (unlikely to have been present at first examination but requiring intervention). RESULTS: An abnormality was detected in 158 (8.8%) infants on first neonatal examination. 1428 (79.6%) babies had a routine second examination, which disclosed 63 previously undetected abnormalities. Of these, seven (11%) would have been present on first examination, 49 (78%) were considered minor, and seven (11%) important--the most consequential being dislocatable hips (four infants). Thus an important finding was detected by only 0.5% of second examinations. CONCLUSIONS: A second thorough examination in the early neonatal period cannot be justified as a screening procedure. A repeat examination of the hips alone in the first week of life is necessary.

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To reduce the number of hours that senior house officers in the neonatal department at Southmead Hospital, Bristol, have to work continuously a new on call rota was devised. The rota changed the traditional one in three system of 24 and 32 hour periods on call to one with two shifts each day, and it spread the workload more evenly among the personnel. The continuity of care of the patients was improved, no extra staff were recruited, and the new system was favoured by senior and junior medical and nursing staff.

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The effectiveness of ethamsylate in the prevention of periventricular haemorrhage (PVH) in very low birthweight infants was evaluated by means of a multicentre, placebo-controlled, double-blind trial. In 330 infants without evidence of PVH on initial cranial ultrasound examination there was little difference between ethamsylate and placebo groups with respect to subependymal haemorrhage, but intraventricular and parenchymal haemorrhages developed in 30/162 infants (18.5%) in the treated group, compared with 50/168 (29.8%) in the control group (p less than 0.02). The incidence of intraventricular and parenchymal haemorrhage in survivors was 20/137 (14.6%) in the ethamsylate group and 37/146 (25.3%) in the controls (p less than 0.05). In 30 infants with evidence of PVH on the initial scan, ethamsylate treatment seemed to limit parenchymal extension. Analysis of the total cohort of 360 infants showed that the proportion of infants in whom an increase of two or more grades of severity of PVH was recorded during the trial was lower in the treated than in the placebo group (p less than 0.01). No adverse effects were attributed to ethamsylate therapy. The reported incidence of patent ductus arterious was lower in the treated than in the placebo group (p less than 0.02). Mortality was similar in the two groups.

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The level of arterial oxygen tension [Pa,o2] at which retrolental fibroplasia (RLF) may develop in very-low-birthweight infants is not known, but may be less than 100 mmHg (13.3 kPa). We report an infant of 27 weeks gestation who developed RLF despite continuous monitoring of Pa,o2 from 2 h to 4 weeks of age, with no recorded values above 95 mmHg (12.7 kPa). We therefore decided to maintain the Pa,o2 below 80 mmHg (10.7 kPa) in very-low-birthweight infants, using when necessary a low oxygen gas mixture (fractional inspired oxygen concentration 0.16-0.20). We report the use of this approach in four infants, all of whom survived without evidence of RLF. The need for further clinical studies of such an approach is discussed.

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In order to assess the potential for "catch-up" growth of the head in "symmetrically" growth retarded infants and the influence of neonatal nutrition, head growth over the first year of life in 18 preterm infants with severe intra-uterine retardation of head growth, but who were otherwise normal, was examined retrospectively. All were delivered before 34 weeks of gestation and, except for 1 with cerebral palsy, showed a significant "catch-up" in head circumference by 10 months post term, with 8/18 stabilizing on or above the fiftieth centile (Fig. 1). This suggests that the reduction in head size in such infants is due to factors extrinsic to the fetus, rather than to a reduced fetal growth potential. Differences in protein and calorie intakes in the neonatal period did not appear to influence the "catch-up".

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Cefotaxime was given to neonates as treatment of infection in a dose of 25 mg/kg 12 hourly by intravenous injection. Blood samples taken by heel-prick were specially treated to minimize any effect of haemolysis on the hydrolysis of cefotaxime. The mean peak plasma concentrations of cefotaxime on the first, second and third days of therapy were 43, 40 and 52 mg/l, respectively, with mean plasma half lives of 4.0, 2.7 and 3.2 h. The mean peak concentrations of desacetyl-cefotaxime were about a quarter of those of cefotaxime, which is in good agreement with adult studies, but much lower than those previously published in studies with neonates. These results emphasize the care that is necessary in the assay of body fluids and tissues for cefotaxime and desacetyl-cefotaxime if accurate results are to be obtained.

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The clinical symptoms associated with coagulase-negative staphylococcal bacteraemia in infants on a Special Care Baby Unit were investigated. They were compared with those of blood culture-negative controls matched for age and weight. Infants with positive cultures were further sub-divided by judging the isolate to be a contaminant or a pathogen. There was a high incidence of respiratory symptoms in the latter patients, particularly in infants of less than 37 weeks gestation. These symptoms often responded to antimicrobial chemotherapy, particularly in infants given correct antibiotics, as demonstrated by laboratory sensitivity testing. Bacteraemia was usually detected shortly after starting mechanical ventilation, and may be its consequence in premature infants. Gentamicin-resistance occurred in over 50 per cent of blood culture isolates of coagulase-negative staphylococci. We postulate that coagulase-negative staphylococci can be a neonatal pathogen requiring appropriate antimicrobial chemotherapy.

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Low birthweight babies fed standard modified cows' milk formulae are at risk from the high fluid intake needed for adequate nutrition, and very preterm babies often develop late hyponatraemia if the sodium intake fails to match large renal losses. A new cows' milk formula (Cow and Gate Prematalac) provides 120 kcal, 3.6 g protein, 7.5 g fat, and 4 mmol sodium in 150 ml. Ten low birthweight babies were fed the new formula at 150 ml/kg a day and compared with 12 similar babies fed a standard modified cows' milk formula (Wyeth SMA Gold Cap) at 180 ml/kg a day. All the babies grew at intrauterine rates and there was no difference in clinical course. None fed the new formula developed hypernatraemia, oedema, or dehydration and none fed the standard formula developed hyponatraemia. The Prematalac group safely excreted the increased osmotic load and had a higher urinary sodium concentration which should protect less mature preterm infants from late hyponatraemia.

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A 30-week gestation boy developed severe unilateral interstitial emphysema whilst being ventilated. This was successfully treated by selective bronchial intubation. The problem of right upper lobe collapse was overcome by using an endotracheal tube with an additional side hole.

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A study of perinatal and neonatal mortality figures for all 36 810 infants born to Avon residents during 1976-9 reported by year of birth and in relation to birth weight, gestational age, and th presence of lethal malformation showed the need for reporting mortality data for normally formed infants weighing 1000 g or more at birth and for assessing perinatal morbidity as well as mortality when attempting to evaluate the standard of perinatal care and the resources required to provide for it.

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