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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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Severe persistent pulmonary hypertension of the newborn (PPHN) remains a significant cause of neonatal morbidity and mortality with limited effective treatment options. We present the first case of a neonate with PPHN treated concurrently with inhaled nitric oxide (iNO) and intravenous prostacyclin (PGI2). He ultimately was diagnosed with alveolar-capillary dysplasia, a rare and fatal cause of pulmonary hypertension. However, his partial response to treatment demonstrates a possible role for combined therapy with iNO and PGI2 in infants with severe PPHN.

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OBJECTIVE: Concern about respiratory depression may lead to underuse of postoperative narcotic analgesia in neonates. The authors compared continuous infusion of fentanyl with bolus dosing in infants after surgery to determine whether continuous infusion is associated with less respiratory depression. STUDY DESIGN: In the first phase of the study, 16 patients were randomly assigned to receive fentanyl by continuous infusion (C) or bolus dosing every 2 hours (B) in a double-blinded trial. Respiratory events were recorded. An observational pain score and saliva for cortisol concentration were obtained 2, 8, and 24 hours after beginning treatment to compare efficacy of pain control. In the second phase, 20 additional patients received fentanyl by continuous infusion in an unblinded fashion, with the same data collection, to more accurately determine the incidence of respiratory events. RESULTS: In phase 1, apnea occurred in eight of nine B patients (89%) compared with one of seven C patients (14%; P < .009), prompting termination of the randomized trial. The incidence of apnea or significant respiratory depression in the next 20 patients (phase 2) who received fentanyl by continuous infusion was 25% (5 of 20; P < .01 v B). Episodes of apnea in B patients required significantly more intervention than episodes in C patients (P < .01). However, in phase 2, more patients remained intubated and ventilated than in phase 1. Pain scores and salivary cortisol concentrations decreased over the 24-hour study period and were similar in B and C patients during both phases of the study. CONCLUSION: Continuous infusion of fentanyl at the doses studied is associated with pain control similar to that with bolus dosing at regular intervals. Although episodes of respiratory depression were less severe and less frequent for C patients, there may be an increased need for ventilator support with continuous infusion of fentanyl to achieve acceptable pain control. Providing adequate pain control to neonates in the immediate postoperative period remains a challenge.

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We noticed that arterial oxygen saturation by pulse oximetry (SpO2) was generally lower when determined by the Ohmeda Biox 3700 pulse oximeter than when determined by the Nellcor N-100 pulse oximeter, and we investigated whether this finding was consistent and the reason for the discrepancy. We placed both oximeters simultaneously on 30 infants with indwelling arterial catheters and measured arterial partial pressure of oxygen (PaO2), percentage of fetal hemoglobin, and complete cooximetry, including arterial oxygen saturation (SaO2) with a Radiometer OSM-3 cooximeter, with and without correction for fetal hemoglobin levels, in four samples of blood from each infant during a 12-hour period for a total of 120 samples. The Nellcor SpO2 was consistently higher than the Ohmeda SpO2 by a mean (+/- SD) of 1.61% +/- 2.69% (p < 0.001). The Nellcor SpO2 correlated best with functional SaO2 (oxyhemoglobin (HbO2)/(HbO2 + reduced hemoglobin)) x 100); Ohmeda SpO2 correlated best with fractional SaO2 (HbO2/(HbO2 + reduced hemoglobin + carboxyhemoglobin + methemoglobin)) x 100), reflecting a fundamental difference in the calibration algorithms used in the two instruments. A desired PaO2 of 50 to 100 mm Hg, is maintained when the range of SpO2 is 90% to 96% for Ohmeda SpO2 and 92% to 98% for Nellcor SpO2 in the neonate, giving a positive predictive value in this study of 94% to 95%. We conclude that SpO2 determined by pulse oximeters of different brands is not interchangeable, and this may be of clinical importance in predicting PaO2 on the basis of SpO2.

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Pulse oximetry is a valuable, noninvasive technique for assessing oxygen saturation that has gained wide clinical acceptance despite little available information concerning normal values in the newborn, especially at an altitude different than sea level. We performed serial pulse oximetry studies on 150 term, appropriate-weight-for-gestational-age, clinically healthy infants at an altitude of 1610 m (5280 ft) at 24 to 48 hours, 1 month, and 3 months of age to define a reference range for oxygen saturation as a guideline in clinical care. We found that mean oxygen saturation at 24 to 48 hours of age is 92% to 93% and varies little with infant activity. With increasing postnatal age, there is a tendency for increased oxygen saturation during the awake states to 93% to 94%, while oxygen saturation during sleep stays the same or even decreases slightly. The lower end of the reference range (2 SDs below the mean) is as low as 85% during feeding at 24 to 48 hours of age, and as low as 86% during quiet sleep at 1 and 3 months of age, with 88% to 89% the lower limit in other activities at all ages.

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To assess the cost of and parental response to home oxygen therapy in the newborn, a telephone survey was conducted of 34 families of infants discharged from our intensive care nursery along with supplemental oxygen therapy. Mean birth weight was 1988 g and gestational age was 33 weeks. The mean length of time oxygen was required at home was 74 days. Savings were estimated for each infant and were found to average $33,370. The typical problems encountered by these families are described. Despite the inconveniences involved, 94% of these families stated they would again take a baby home while oxygen dependent if necessary.

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Necrotizing enterocolitis (NEC) is commonly thought of as occurring in the sick premature infant, usually in the first one to two weeks of life. A review of NEC at the Children's Hospital of Denver over a 5-year period, found that 13 of 79 infants (16.1%) had onset of NEC during the first day of life. These infants were larger (mean birth weight 2,624 +/- 849 g), more mature (mean gestational age 37.9 +/- 2.5 weeks), and less asphyxiated as judged by Apgar scores (mean five-minute score 8.15 +/- 1.07) than infants with onset of NEC after the first day of life (mean birth weight 1,519 +/- 586 g, mean gestational age 32.0 +/- 3.5 weeks, P less than .001, and mean five-minute Apgar score 6.81 +/- 1.84, P less than .05). Despite their large size and degree of maturity, eight of these infants (62%) showed signs of respiratory distress; four (31%) were polycythemic; four (31%) had either a partial or double-volume exchange transfusion performed; and 11 (85%) were fed prior to developing NEC. Presenting signs of disease, occurrence of sepsis (31%), requirement for surgical intervention (62%), and mortality (30%) were similar for the two groups of infants. It is suggested that term and near-term infants who have significant illness after delivery be treated more like their premature counterparts with cautious introduction of feedings after an adequate period of stabilization.

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