Somatosensory Evoked Potentials in Neonatal Jaundice

ABSTRACT. Somatosensory evoked potentials (SEPs) were studied in jaundiced and normal neonates on the day the highest bilirubin values were reached, 2-3 days later, and at five weeks. During the first week three groups were formed according to peak bilirubin values: A: 250 μmol/I (n=20), B: 125-250 μmol/I (n=6), C: <125 μmol/I or no jaundice (n=19). At five weeks 10 infants of group A were reinvestigated, together with 17 controls. Cervical (N13) and scalp SEPs (N19) were recorded with a variable number of stimuli. The SEPs of group B and C did not differ from each other. In group A the N13 peak latencies were within the range of group C at the first investigation, but prolonged at the second and third. The cortical components were prolonged at the first investigation, improved but still prolonged at the second, while the N19 peak latency was still prolonged at the third investigation. The central conduction time (CCT) correlated positively with the bilirubin level. Since a rapid decrease in the N19 amplitude was found for all groups from 25 to 100 stimuli, recordings should be done with a low number of stimuli (less than 100). Our findings indicate that both the periferal and the central components of the SEPs in the neonatal period are delayed by jaundice and that full recovery is not obtained at five weeks. The non-invasive SEP technique can be used as a daily monitor of the effect of bilirubin on the CNS.     

INCREASING INCIDENCE OF NEONATAL SEPTICEMIA: CAUSATIVE ORGANISM AND PREDISPOSING RISK FACTORS

ABSTRACT. Bennet, R., Eriksson, M. and Zetterstrom, R. (Department of Paediatrics, Karolinska Institute, St. Göran's Children's Hospital, Stockholm, Sweden). Increasing incidence of neonatal septicemia: Causative organism and predisposing risk factors. Acta Paediatr Scand, 70:207, 1981. –The incidence of neonatal septicemia in the referral area of St. Göran's Children's Hospital in Stockholm has been studied during a ten-year period (1969–1978). An increase was noticed during the period 1974–1978 in comparison with the preceding five-year period. The incidence per 1000 live births was 1.4 and 3.1, respectively. The incidence of osteoarthritis increased from 0.21 to 0.41 per 1000. Mortality rate from neonatal septicemia remained unchanged. Gram-negative organisms as an etiologic factor seemed to be decreasing while staphylococcal infections have increased. Group B streptococcal infection occurred with the same frequency during the whole period. The low incidence of enteric organisms might be related to the common practice of feeding the babies with milk from their own mothers. Perinatal risk factors were equally common in both five-year periods. The observed increase of the prevalence of neonatal septicemia caused by Staphylococcus aureus may be explained by a higher rate of survival of highly susceptible low-birthweight infants and other sick neonates treated in the neonatal intensive care unit.     

Angiography and the conservative management of neonatal adrenal haemorrhage

Neonatal angiography provided an additional criterion in the diagnosis of unilateral neonatal adrenal haemorrhage. Non-operative management was thus enabled. It is suggested that the prevalent operative approach to all neonatal perirenal masses should be revised.     

Physician counselling practices and decision-making for extremely preterm infants in the Pacific Rim

OBJECTIVES: This study was undertaken to evaluate physician counselling practices and resuscitation decisions for extremely preterm infants in countries of the Pacific Rim. We sought to determine the degree to which physician beliefs, parents' opinion and medical resources influence decision-making for infants at the margin of viability. METHODS: A survey was administered to neonatologists and paediatricians who attend deliveries of preterm infants in Australia, Hong Kong, Japan, Malaysia, Taiwan and Singapore. Questions were asked regarding physician counselling practices, decision-making for extremely preterm infants and demographic information. RESULTS: Physicians counsel parents antenatally with increasing frequency as gestational age increases. Most physicians discuss infant mortality and morbidity with parents prior to delivery. Physicians less frequently discuss the option of no resuscitation of an extremely preterm infant, withdrawal of support at a later time, or financial costs to parents. Severe congenital malformations, perception of a poor future quality of life, parental wishes and a high probability of death for the infant are influential in limiting resuscitation in very preterm infants for a majority of physicians. Less influential factors are parent socioeconomic status, language barriers, financial costs for the family, allocation of national resources, moral or religious considerations, or fear of litigation. Physician thresholds for resuscitation of infants ranged between 22 and 25 weeks gestation and between 400 and 700 g birthweight. CONCLUSIONS: We report physician beliefs and practices regarding resuscitation and the counselling of parents of extremely preterm infants in Pacific Rim countries. While we find variation among countries, physician practices appear to be determined by ethical decision-making and medical factors rather than social or economic factors in each country.     

Neonatal sepsis and infection control policies in Australia

The pattern of neonatal bacterial infection, its management and the types of infection control policy were ascertained in 20 neonatal intensive care units (NICU) in Australia by questionnaire survey. Group B Streptococcus and Escherichia coli were the predominant organisms responsible for perinatally acquired infection for which the most common antibiotic combination used was Penicillin and Gentamicin. Staphylococcus epidermidis and aureus (majority Methicillin resistant) were the predominant organisms responsible for nosocomial infection for which the most common antibiotic combination used was Vancomycin and Cefotaxime. A Serratia epidemic was experienced in four NICU. Lumbar and suprapubic punctures were frequently done as part of the diagnostic workup in nosocomial infections but not with perinatally acquired infections. Haematological indices considered useful as a diagnosis aid varied between NICU and acute phase reactants were rarely relied upon for diagnosis or for monitoring treatment response. Granulocyte transfusion and intravenous immunoglobulins were infrequently used in therapy. No consensus was found on infection control policies. Eight NICU required routine gowning on entry, two restricted sibling visiting and four restricted visiting by relatives and friends. Although routine bacteriological surveillance on staff or equipment was uncommon, serial cultures were carried out in infants from the body surface in six NICU and from the endotracheal aspirate in 17 NICU. Antiseptics used with technical procedures included iodine, chlorhexidine and alcohol used singly or in combination. Skin and umbilical cord care also varied between NICU. The literature was reviewed to determine the effectiveness or otherwise of some of the existing policies in the prevention or management of neonatal infection to encourage consensus towards a more rational approach to neonatal infection in Australia.     

An evaluation of the autopsy following death in a Level IV neonatal intensive care unit

OBJECTIVE: To ascertain the determinants of neonatal autopsy, define clinical errors in the causes of death, and elucidate the possible audit and genetic value of the autopsy following death in a Level IV neonatal intensive care unit (NICU). METHODS: A review and correlation of clinical and autopsy information in a case series of infants who died during the period 1991-97. RESULTS: Two hundred and twenty-nine of 4057 infants admitted to the NICU died and 91 (39.7%) underwent an autopsy. The underlying cause of death was significantly different in infants who had an autopsy compared with infants who did not (P = 0.02). The autopsy rate was higher for deaths from miscellaneous causes (52.9%), lethal malformation (46.8%) and infection (45.4%) than deaths from prematurity (25.9%) and asphyxia (19%). Clinical errors in the causes of death were found in 22% of the infants, and in 4.4% a change in management may have been curative or prolonged life. The autopsy had audit value in 26% of infants and genetic value for a single gene (Mendelian) disorder in 4.4%. CONCLUSIONS: Although the autopsy following death in a Level IV NICU yields potentially useful information in more than one-third of cases, this does not seem sufficient to ensure a high neonatal autopsy rate.     

Review of neonatal alloimmune thrombocytopenia

Neonatal alloimmune thrombocytopenia (NAIT), with an incidence of one in 1000 live births, is the most common cause of severe thrombocytopenia and intra-cerebral haemorrhage in term neonates. NAIT results from trans-placental passage of maternal antibodies against a paternally derived fetal platelet alloantigen. Clinical presentation varies from unexpected thrombocytopenia on a blood film in a well newborn to intracranial haemorrhage (ICH). In contrast to haemolytic disease of the newborn, NAIT can present in a first pregnancy, and subsequent pregnancies are usually more severely affected. The role of antenatal screening for maternal alloantibodies instead of fetal blood sampling to identify at-risk fetuses remains uncertain, but there is a trend towards less invasive maternally directed treatment for at-risk pregnancies. Neonatal management is aimed at preventing or limiting thrombocytopenic bleeding with transfusion of antigen-matched platelets.     

Clinical features of malaria in neonates

Seven neonates havingP. vivax infection were studied. The common presenting features were fever, hepatomegaly, splenomegaly, anemia and jaundice. Few also had respiratory difficulty, feeding difficulty and gastroenteritis. The anemia was mostly hemolytic in nature with raised serum bilirubin, alkaline phosphatase and reticulocytosis.     

Neonatal malaria

Fifteen neonates were diagnosed to have malaria from July 1973 through October 1975. The mothers of these infants were young (mean age 25 years). Malarial parasites were demonstrated in the blood in ten of 15 mothers during pregnancy or puerperium. The age of onset of symptoms in the neonates varied from 6 to 24 days (mean 19 days). Clinical features charcteristic of malaria in early infancy were apathy and failure to suck, particularly marked during periods of high fever and later attended with progressive pallor and splenomegaly. One infant died and the rest 14 were cured wilh chloroquine.     

PATHOLOGY TEACH AND TELL: NEONATAL HEMOCHROMATOSIS WITH MASSIVE HEPATIC NECROSIS

Neonatal hemochromatosis (NH) is an uncommon disorder clinicopathologically defined by severe liver disease of intrauterine onset associated with extrahepatic siderosis that spares reticuloendothelial elements. NH phenotypically is a similar disorder to hereditary hemochromatosis. However, its extremely early onset of liver failure makes it notably unique. Massive liver necrosis in the newborn is a rare occurrence, but whenever present hemochromatosis should be considered in the differential diagnosis. Herein, we report a case of neonatal hemochromatosis that had massive hepatic necrosis with sparing only little parenchyma. The outcome was fatal within the first month of life.     

Is intensive care for very immature babies justified?

Neonatal intensive care is generally considered justified in the majority of very premature infants, but there is some concern about the effectiveness of the techniques used at the margins of viability (22-24 wk of gestation). The controversy that exists in this area is largely due to a lack of agreed endpoints for geographically based populations where all live births are considered. Evaluation of outcome must also take the quality of neurological function in surviving infants into consideration, and in reviewing these data the reader is struck by the few reports providing information on a high proportion of survivors. To inform this debate, the "best data" for analysis are reviewed based on a number of criteria of quality for survival and outcome studies. Based on these data sets, < 25% of babies born alive at 24 wk and below survive without major disability. CONCLUSION: An objective review of "best data" will provide the basis of an informed debate on whether providing intensive care for all very immature babies is appropriate in developed countries.     

Laparotomy for necrotizing enterocolitis: Intensive care nursery compared with operating theatre

OBJECTIVE: To determine whether neonates requiring laparotomy for necrotizing enterocolitis (NEC) are more stable perioperatively and have less disruption of physiological parameters if surgery is performed in the neonatal intensive care unit (NICU) compared with the operating theatre (OR). METHODOLOGY: A retrospective case review was performed on 233 neonates referred for further surgical management of severe NEC in the period January 1989 to December 1997. Mortality and morbidity were compared by calculating the score for neonatal acute physiology (SNAP) and its attendant risk of mortality score. Thirty-six separate physiological variables were also compared pre- and postoperatively and the mean postoperative change was calculated. RESULTS: For neonates weighing less than 1500 g, mortality was linked to illness severity, as measured by SNAP, rather than operative location. Specific adverse events associated with secondary transfer to the OR included hypothermia, deterioration in oxygenation parameters, ventilation parameters and platelet count. The liberal use of blood products, albumin and bicarbonate in perioperative resuscitation may have obscured other effects. CONCLUSIONS: The use of the neonatal intensive care nursery for surgery on neonates weighing less than 1500 g with severe NEC can be justified and such use should be encouraged. In contrast, secondary transport of neonates weighing less than 1500 g to the OR for laparotomy is associated with significant deterioration in a number of physiological parameters, which may impact on morbidity.