Persistent high activity of the fetal adrenal cortex in preterm infants: is there a clinical significance?

BACKGROUND: In preterm infants, the activity of the fetal adrenal cortex continues until term. Dehydroepiandrosterone sulphate can block the synthesis of surfactant in vitro. The incidence of pulmonary disease is higher in male than in female preterm infants. OBJECTIVE: To investigate the relationship between urinary excretion of fetal zone steroids (3beta-OH-5-ene-steroids) and the severity of lung disease in preterm infants with respect to gender. PATIENTS AND METHODS: 3beta-OH-5-ene-steroids were profiled by gas chromatography-mass spectrometry in 24-h urinary samples in 61 preterm infants of less than 30 weeks gestational age. RESULTS: The incidence of respiratory distress syndrome treated with surfactant in females (n = 30) was 47% and in males (n = 31) 71%, p = 0.07. Medians of total excretion rates of fetal zone steroids (microg/kg/d) in female (male) preterm infants were at day 1: 1,317 (895); day 2: 3,154 (7,723), p = 0.03; day 3: 5,502 (9,494), p = 0.08; day 5: 7,140 (10,407); week 2: 8,731 (9,720); week 3: 8,571 (10,079); week 4: 7,620 (7,825). Regression analysis did not reveal a significant influence of maximum excretion rates of fetal zone steroids or gender on the incidence of respiratory distress syndrome treated with surfactant. CONCLUSIONS: Excretion rates of fetal zone steroids were 4-fold higher than previously reported indicating a persistent high activity of the fetal adrenal zone in preterm infants. Excretion rates of fetal zone steroids were significantly higher in male preterm infants compared to females at day 2 (trend at day 3) but did not have a significant influence on the incidence of respiratory distress syndrome.     

Prenatal treatment of congenital adrenal hyperplasia due to 21-hydroxylase deficiency: A 10 year experience

Conclusion Administration of dexamethasone to mothers at risk of having children with CAH due to 21-OH deficiency is effective in suppressing fetal adrenals and preventing masculinisation of female external genitalia. Treatment should be started early, before the 7th week of gestation and should be administered as 2 or 3 divided doses. Compliance to treatment and efficacy of fetal adrenal suppression should also be carefully evaluated. The study presented here favours a daily dose of dexamethasone related to maternal size, i.e. 20–25 μg of dexamethasone per kg of maternal body weight at the time of onset of treatment. Mode of prenatal diagnosis would depend on the family and the facilities available locally. This article is based on the presentation in the “International Workshop on Recent Advances in Neonatal Surgery and Intersex Disorders” held at All India Institute of Medical Sciences, New Delhi from March 1–4, 1989. It was accepted for publication in 1991.     

Multiple courses of antenatal steroids

The benefits and risks of multiple courses of antenatal steroids (ANS) are still unresolved issues. This was a prospective cohort study in a level III neonatal unit. Preterm babies ≤35 wk gestation were included. Malformations, chronic maternal steroid intake, exchange transfusions prior to cortisol sampling and incomplete ANS courses were exclusion criteria. Subjects were classified into: No course (Group 0), 1 course (group 1), 2 courses (Group 2), >2 courses (Group 3) of antenatal dexamethasone. The key outcome was adrenal function assessed by basal and post-ACTH cortisol on day 3. Other outcomes were neonatal morbidity, mortality, growth parameters at birth, long term growth and neuro-development. Of 210 eligible babies, 124 were enrolled. 38, 51, 10 and 25 babies belonged to groups 0, 1, 2 and 3 respectively. Basal and post-ACTH serum cortisol did not show any significant difference between groups (p=0.5 and p=0.9 respectively). Incidence of severe HMD requiring ventilation was significantly lower (p=0.02) in multiple course group (combined groups 2 and 3) compared to single course group. There were no differences in other neonatal morbidity, birth OFC and weight between single and multiple ANS groups. Follow up data at a mean age of 22 mth was available in 59 subjects (69%) belonging to groups 1–3. No differences were noted in the proportion of patients with abnormal neurological examination (p=0.1), abnormal PDI (p=0.9), abnormal MDI (p=0.9) and physical growth between multiple and single course groups. Multiple courses of antenatal dexamethasone resulted in a significant decrease in severe forms of RDS and they did not cause adrenal suppression, decreased growth or impaired neurodevelopment.     

Prenatally diagnosed cystic neuroblastoma

An exceedingly rare case of prenatally diagnosed cystic neuroblastoma (NB) is described. Prenatal ultrasonography at 28 weeks' gestation revealed a cystic right suprarenal mass that measured 15 × 17 mm in diameter. The mass increased parallel to fetal size until it was 41 × 44 mm in diameter at 39 weeks' gestation. Magnetic resonance imaging performed prenatally and after delivery showed two different intracystic intensities with fluid levels, suggesting intracystic hemorrhage. The patient underwent a right adrenalectomy at 20 days of age, and the resected tumor was diagnosed as a poorly-differentiated ganglioneuroblastoma. Eight months after surgery, the patient is generally healthy with no evidence of recurrence. We reviewed 25 additional cases of prenatally diagnosed adrenal cystic NB and examined the clinical features of this rare entity. Accepted: 25 November 1997     

Hypertrophic cardiomyopathy in preterm infants treated with dexamethasone

Steroid therapy has been widely used in neonates for its beneficial effects. Adverse side-effects have been described, also affecting the cardiovascular system. We report two cases of hypertrophic cardiomyopathy in two preterm newborns secondary to dexamethasone treatment. Full recovery occurred after discontinuing steroids. Risk/benefit ratios must be carefully considered before using steroids in the neonatal period. Conclusion Serial echocardiographic evaluations should be performed to evaluate prevalence and clinical rel-evance of hypertrophic cardiomyopathy in preterm in-fants treated with dexamethasone. Received: 9 July 1996 / Accepted: 31 October 1996     

Adrenal response in very low birthweight babies after dexamethasone treatment for bronchopulmonary dysplasia.

The tetracosactrin stimulation test was used to assess the adrenal responsiveness of 22 very low birthweight babies who had received a three week course of dexamethasone for the treatment of bronchopulmonary dysplasia. Five babies were studied in detail with blood samples taken for cortisol concentrations at 30 minute intervals for four hours. The tests were performed before, during, and after treatment with dexamethasone. A distinctive pattern of cortisol response to tetracosactrin was found among these babies, which was quite unlike that found in older children and adults. Using our pretreatment results as control data we conclude that there is undoubtedly evidence of modest suppression of the adrenal axis during dexamethasone treatment, although there is considerable recovery one month after stopping steroids. Basal cortisol concentrations, however, remained low in some cases, which may indicate the need for temporary corticosteroid replacement during severe illness.     

Free fatty acids and triglycerides in normoglycemic low birth weight newborns in early neonatal period

Free fatty acids, triglycerides and blood sugar were estimated in 45 lowbirth weight which included 24 preterm and 21 small for gestational age term babies, in the cord blood, in the fasting state at 6±1 h of age, and after initiation of sugar water feeds at 24±2 h of age. Thirty six appropriate for gestational age, term newborns were taken as controls. None of the newborns were born to diabetic mothers or had hypoglycemia. Mean cord blood sugar levels in all the groups were similar ranging between 69.55 to 73.7 mg/dl. followed by a fall in all at 6±1 h and subsequent rise at 24±2h. levels were significantly lower in LBW newborns compared to controls. Means FFA levels were lowest in babies with agestation of 28–32 weeks (0.27 m Mol/L), being almost similar to controls (0.35 mMol/L) in preterm 33–36 weeks (0.32 mMol/L) and higher than controls in SGA (0.48 mMol/L). An inverse relationship with blood sugar level was seen in serial estimations. SGA neonates continued to show higher and preterm (28–32 weeks) lowest levels throughout the study period. Triglycerides in cord blood were 36.72 mg/dl, 38.33 mg/dl, 56.23 mg/dl and 40.11 mg per cent in preterm 28–32 weeks, 33–36 weeks, SGA term and controls respectively. Levels showed a steady rise during the study period.     

Managing the assessment of neonatal jaundice : Importance of timing

In view of the limitations in the accurate visual assessment of jaundice and its potential role as a predictive vector for serious neurologic sequelae, we propose that a universal screening of bilirubin be considered concurrent to the routine pre-disharge metabolic screening. Universal bilirubin screening in the term and near-term newborns when plotted on “Hour-specific Bilirubin Nomogram” in lieu of the usual “day-specific” value will predict the high-risk and the low-risk groups and facilitate cost-effective and individualized follow-up of those babies at risk. A percentile based bilirubin nomogram for the first week of age was constructed from hour-specific pre-and post-discharge bilirubin values of 2840 healthy term and near-term babies. The accuracy of the pre-discharge bilirubin values was determined as a predictive vector. Pre-discharge (18–72 hours age), 6.1% of the study population had bilirubin values in the high-risk zone (>95th percentile). Of these, 39.5% remained in that zone (likelihood ratio {LR}=14.08). Pre-discharge, 32.1% of the study population had bilirubin values in the intermediate risk zone (40–75th percentiles). In a clinically significant minority of these babies (6.4%), the post-discharge values moved to the high-risk zone (L−R=3.2 for the move from the upper-intermediate zone and 0.48 from the lower-intermediate zone). In the remainder 61.8% of the population who were identified to be at low risk, there was no measurable risk for significant hyperbilirubinemia (L–R =0). The bilirubin nomogram can predict which infant is at high, intermediate, and low risk for subsequent excessive hyperbilirubinemia and allows for the individualized follow-up of these high-risk babies with particular attention to those who may need evaluation and intervention. Whereas, identification of the low risk group allows for a less intense bilirubin follow-up and in whom a visual check by an experienced care-provider may suffice.     

Cesarean section for suspected fetal distress, continuous fetal heart monitoring and decision to delivery time

Objective  To find out the efficacy of continuous fetal heart monitoring by analyzing the cases of cesarean section for nonreassuring fetal heart in labor, detected by cardiotocography (CTG) and correlating these cases with perinatal outcome. To evaluate whether a 30 minute decision to delivery (D-D) interval for emergency cesarean section influences perinatal outcome. Methods  This was a prospective observational study of 217 patients who underwent cesarean section at ≥ 36 weeks for non-reassuring fetal heart in labor detected by CTG. The maternal demographic profile, specific types of abnormal fetal heart rate tracing and the decision to delivery time interval were noted. The adverse immediate neonatal outcomes in terms of Apgar score <7 at 5 minutes, umbilical cord tH <7.10, neonates requiring immediate ventilation and NICU admissions were recorded. The correlation between non-reassuring fetal heart, decision to delivery interval and neonatal outcome were analyzed. Results  Out of 3148 patients delivered at ≥ 36 weeks, 217 (6.8%) patients underwent cesarean section during labor primarily for non-reassuring fetal heart. The most common fetal heart abnormality was persistent bradycardia in 106 (48.8%) cases followed by late deceleration in 38 (17.5%) cases and decreased beat to beat variability in 17 (7.8%) cases. In 33 (15.2%) babies the 5 minutes Apgar score was <7 out of which 13 (5.9%) babies had cord tH <7.10. Thirty three (15.2%) babies required NICU admission for suspected birth asphyxia. Rest 184 (84.7%) neonates were born healthy and cared for by mother. Regarding decision to delivery interval of ≤30 minutes versus >30 minutes, there was no significant difference in the incidence of Apgar score <7 at 5 minutes, cord pH <7.10 and new born babies requiring immediate ventilation. But the need for admission to NICU in the group of D-D interval ≤ 30 minutes was significantly higher compared to the other group where D-D interval was >30 minutes. Conclusion  Non-reassuring fetal heart rate detected by CTG did not correlate well with adverse neonatal outcome. There was no significant difference in immediate adverse neonatal outcome whether the D-D time interval was ≤ 30 minutes or >30 minutes; contrary to this, NICU admission for suspected birth asphyxia in ≤ 30 minutes group was significantly higher.     

Glucocorticoid receptors in circulating lymphocytes of premature infants and newborns

The number and affinity of glucocorticoid receptors in lymphocytes of newborns and prematures were determined by a whole cell 3H-dexamethasone binding assay. Mean receptor numbers were, 1758 +/- 245/cell in cord blood, 2758 +/- 307/cell in mature newborns and 2025 +/- 485/cell in prematures. Three of the premature babies died with hyaline membrane disease (HMD). They had not been treated prenatally with dexamethasone and no specific binding was measurable in their lymphocytes, suggesting that the lack of receptors might be one of the causes of HMD.     

Relationship between length of gestation,birth weigth and certain other factors

Summary A prospective study of 9000 single live born babies with known gestation was conducted during the period January 1967 to June 1970 with a view to find out incidence of prematurity, relationship between gestation and birth weight and other anthropometric measurements. Feeding and respiratory problems along with mortality rate was studied for accurate appraisal of the newborns. The incidence of prematurity on the basis of 2000 G. and below was 11.27% as compared to 48.16% when based on the international standard of 2500 G. Prematurity in the gestational age group of 37 weeks or less was only 10.9% which was further reduced to 9.07% when gestation below 37 weeks and weight below 2500 G. were combined. Majority of the babies below 2500 G. (81.17%) had gestation period more than 37 weeks. In the same weight group all the anthropometric measurements were higher in babies with longer gestation. A higher mortality was observed amongst the same group of babies with low birth weight and shorter gestation. Prognosis improved with increase in weight and in the length of gestation. Physiological response was more mature in the babies with longer gestation in the same weight group. On the basis of the above observations the authors suggest that for correct and accurate appraisal of the newborn, gestation, birth weight with other anthropometric measurements, functional maturity, different clinical problems peculiar to newborns and mortality should be studied in combination and where this is not possible, babies below 2000 G. with gestation less than 37 weeks should be labelled ‘Premature Low Birth Weight Infants’ and babies between 2000–2500 G. with gestation more than 37 weeks be labelled ‘Full Term Low Birth Weight Infants’. This study was partially supported by a grant-in-aid by the Indian Council of Medical Research, New Delhi-16.     

Is a normally functioning gastrointestinal tract necessary for normal growth in late gestation?

It is known that neonates with congenital abnormalities of the intestine tend to be growth-retarded. We wished to explore the hypothesis that normal fetal gut function is needed for normal growth in late gestation. If this is true, then different populations of babies with different congenital gut abnormalities would be expected to have similar impairments of growth and be small at birth. This growth retardation would be more marked in term than in preterm babies and would be independent of other congenital anomalies. To test these hypotheses, we examined 43 babies born with gastroschisis (GS) in Auckland, New Zealand; 69 babies born with GS in Birmingham, England; and 60 babies born with intestinal atresia (IA) in Auckland. For Auckland babies with GS, the mean weight standard deviation score (WSDS) (i.e., birth weight relative to the mean birth weight for gestation) for term babies was lower than that for preterm babies (−0.932±0.180 vs −0.064±0.237, P=0.014). This was also true for Birmingham babies with GS (−0.991±0.193 vs −0.36 ±0.153, P=0.028). For babies with IA, the mean WSDS for term babies was lower than that for preterm babies (−0.627±0.266 vs 0.057±0.211, P=0.034). There was no significant difference between the mean WSDS of babies with and without major congenital abnormalities (−0.402±0.201 vs −0.271, P=0.70). Our results demonstrate that term babies born with GS are significantly growth-retarded compared with premature babies born with GS. Term babies born with a proximal IA are also growth-retarded. This strongly suggests that in late gestation, the normal growth is dependent on a normally functioning gastrointestinal tract that allows exposure of the proximal intestinal mucosa to ingested amniotic fluid. Accepted: 9 December 1996     

Teratomas of the neck and mediastinum in children

This retrospective study reviews a series of teratomas of the neck and mediastinum aiming at defining the features of these particular locations. We recorded prenatal diagnosis, perinatal management, clinical and radiologic features, pathology, surgical strategies and results in cervical and mediastinal teratomas treated over the last 10 years. During this period we treated 66 children with teratoma of which 11 (6 male and 5 female) had cervicomediastinal locations. Five babies had cervical teratomas extended into the anterior mediastinum in two cases. Prenatal diagnosis was made in three (two with polyhydramnios). Four babies were born by C-section and only one had a successful EXIT procedure. The diagnosis was confirmed by imaging and increased AFP. Surgical treatment involved total tumor removal and in one case subsequent removal of lymph node metastases. All children survived except one in whom airway could not be cleared at birth. Two children bear mild hypothyroidism. During the same period six patients aged 0–17 years were treated for mediastinal teratoma. Only one was prenatally diagnosed and only two had some dyspnea. Removal was performed either by median sternotomy, thoracotomy, or thoracoscopy. They all survive and are free of disease. Teratomas of the neck may cause fetal disease and unmanageable neonatal airway obstruction. Prenatal diagnosis and planned multidisciplinary management are mandatory at birth. In contrast, only some mediastinal tumors cause respiratory embarrassment. Although benign, these tumors are sometimes immature and may metastasize to regional lymph nodes. Total surgical removal is curative. Thyroid insufficiency may be present at birth in cervical teratomas and may be aggravated by surgery.     

Cord blood α-fetoprotein concentrations in term newborns of smoking mothers

To investigate the toxic effect of tobacco smoke on the fetus, we measured in cord blood the concentrations of α-fetoprotein (AFP), the principal serum protein in early ontogenic development, and erythropoietin (EPO), as an index of chronic fetal hypoxia. A total of 103 consecutively enrolled term newborns of smoking mothers and 103 term infants of nonsmoking parents were studied. The mean ± SD AFP concentrations in the newborns of the mothers who smoked 1–50, 5–50, and 10–50 cigarettes/day were 86.4 ± 88.9, 96.3 ± 91.9 and 118.7 ± 103.7 ng/ml, respectively. The difference of all three groups from the control neonates (57.7 ± 37.2) was significant. The EPO concentrations in the newborns of the mothers who smoked 1–50 (53.9 ± 64.6 mU/ml) and 5–50 (56.3 ± 68.5) cigarettes/day were significantly greater than in the control neonates (29.5 ± 16.1). In the newborns of the smoking mothers there was a significant positive correlation between AFP concentrations and number of cigarettes smoked per day, and a negative correlation between AFP and birth weight or length. There was no correlation between AFP and EPO concentrations, as well as between EPO and birth weight, length or number of cigarettes smoked per day. Conclusion The absence of a correlation between erythropoietin and birth weight or length and the negative correlations between α-fetoprotein and these anthropometric parameters suggest that the intra-uterine growth retardation caused by maternal smoking is not due to tissue hypoxia, but that both growth retardation and elevated α-fetoprotein result from the direct or indirect toxic effect of a factor(s) present in tobacco smoke. Received: 22 June 1998 / Accepted in revised form: 17 November 1998     

Daily periods of aldosterone, sodium, and potassium excretion in the urine of newborns, infants, and children: influence of long-term steroid treatment and of the blockage of adrenergic beta-receptors (author's transl)]

Aldosterone, sodium, and potassium excretion in the urine of six newborns (5, 6, and 9 days), seven infants (2, 3, 4, and 6 months) and eight children (4, 5, 6, 12, and 15 years) was determined at 3-hour intervals during a 24-hour period via gas chromatography and/or flame photometry. The circadian rhythmn of aldosterone excretion could already be ascertained in the 5-day-old newborns. All babies and children examined showed a distinct increase in aldosterone excretion between 3 and 6 am or 6 and 9 am. On the overage, 41% of the total daily amount was excreted between 3 and 9 am. Excretion of sodium and potassium was very low for the newborns and infants. Only in small children and in school children did sodium excretion and the molecular relationship Na/k in urine have a statistically significant negative correlation with the excretion of aldosterone. After long-term prednisone therapy, the maximum amount of aldosterone was excreted in the afternoon. The findings after treatment with propranolol and administration of dexamethasone over a three-day period were similar.     

Bone and joint infection in neonates

A retrospective study was done to review the clinical experience of septic arthritis and osteomyelitis in the newborns in our centre. Case records of all the neonates born from January 1989 to August 1994 and those admitted to outborn nursery from 1985 to 1993 were reviewed. Diagnosis of septic arthritis/osteomyelitis was made in the presence of relevant clinical signs and supported by positive culture from blood or joint fluid and abnormal X-ray or ultrasound findings. The incidence of septic arthritis and osteomyelitis among inborn babies was 1 in 1500. There were 25 neonates with mean gestational age 34.5 (range 27–40) weeks and mean birth weight 2269 (range 990–4750) gms. Limitation of movement (64%) and local swelling (60%) were commonest presentations. A total of 33 joints were involved in 25 babies. Eight babies (32%) had multiple joint involvement. Hip and knee were the most commonly involved joints (48% each). In 19 babies (76%) joint involvement occurred in association with a generalized septicemic illness while 6 babies (24%) had localised signs and symptoms. Joint aspirate was positive for gram stain or culture in 12 (48%) and 10 babies (40%) had positive blood culture.Klebsiella pneumoniae andStaphylococcus aureus were commonest isolates. Radiological changes were seen in 13 (52%) babies. All were treated with appropriate antibiotics and open surgical drainage was done in 5 (20%) cases. Bone and joint infections are important complications in sick septicemic neonates and need early diagnosis, appropriate management with antibiotics, surgical drainage in selected cases to prevent long term morbidity.     

Prevention of hypernatraemic dehydration in breastfed newborn infants by daily weighing

Hypernatraemic dehydration, which predominantly appears in breastfed neonates, can cause serious complications, such as convulsions, permanent brain damage and death, if recognised late. Weight loss ≥10% of birth weight could be an early indicator for this condition. In this prospective cohort study from October 2003 to June 2005 in the postnatal ward of the University Hospital Zurich, Switzerland, all term newborns with birth weight ≥2,500 g were weighed daily until discharge. When the weight loss was ≥10% of birth weight, serum sodium was measured from a heel prick. Infants with moderate hypernatraemia (serum sodium = 146–149 mmol/l) were fed supplementary formula milk or maltodextrose 10%. Infants with severe hypernatraemia (serum sodium ≥150 mmol/l) were admitted to the neonatal unit and treated in the same way, with or without intravenous fluids, depending on the severity of the clinical signs of dehydration. A total of 2,788 breastfed healthy term newborns were enrolled. Sixty-seven (2.4%) newborns had a weight loss ≥10% of birth weight; 24 (36%) of these had moderate and 18 (27%) severe hypernatraemia. Infants born by caesarean section had a 3.4 times higher risk for hypernatraemia than those born vaginally. All newborns regained weight 24 h after additional fluids. Conclusion: In our study, one out of 66 healthy exclusively breastfed term neonates developed hypernatraemic dehydration. Daily weight monitoring and supplemental fluids in the presence of weight loss ≥10% of birth weight allows early detection and intervention, thereby preventing the severe sequellae of hypernatraemic dehydration.     

Virilizing adrenal adenoma in a 2-year-old girl

A 2-year-old girl with virilization had an adrenal tumor that produced testosterone with little evidence of excessive urinary androgen excretion. Plasma testosterone concentration was 407 ng/dL and urinary 17-ketosteroid (17KS) levels were 3 and 2 mg/day. Excretion of 17KS decreased to 1.8 mg/day after suppression of dexamethasone therapy, but urinary 17-hydroxycorticosteroid excretion did not change from 1.0 to 0.7 mg/day after administration of dexamethasone. She had a blunted response to administration of metyrapone and insulin and a small diurnal variation in cortisol concentration suggesting suppression of corticotropin secretion, even though the plasma cortisol concentration was in the normal range and there were no clinical signs of cortisol excess. High-performance liquid chromatography was used to analyze the steroid content of tumor tissue. Those portions of the tumor that were rich in steroids contained predominantly testosterone.     

Prenatal treatment of congenital adrenal hyperplasia resulting from 21-hydroxylase deficiency

In an attempt to prevent in utero virilization of female fetuses with 21-hydroxylase deficiency, six mothers at risk were treated with either hydrocortisone (n = 1) or dexamethasone (n = 5) in early pregnancy. Treatment was continued to term in the two pregnancies in which the diagnosis of an affected female fetus was confirmed. In patient 1 (hydrocortisone treatment) fetal adrenal suppression was only partial but the external genitalia were only slightly abnormal. In patient 2 (dexamethasone treatment) fetal adrenal suppression was achieved and the external genitalia were normal at birth. These encouraging results open a new prospect for treating congenital adrenal hyperplasia in utero.     

Diagnostic potential of neutrophil elastase inhibitor complex in the routine care of critically ill newborn infants

It has been suggested that determination of the neutrophil elastase α1-proteinase inhibitor complex (E-α1PI) improves the diagnosis of bacterial infection in newborns. We evaluated the use of E-α1PI measurements in 143 newborns, consecutively admitted to a tertiary intensive care unit, employing a new random access assay and a sampling procedure that minimises post-collection artefacts. The 95% range for non-infected newborns was 20–110 μg/l up to the 5th day of life and 20–85 μg/l thereafter. The sensitivity as to the diagnosis of culture-proven bloodstream infection was 80% for E-α1PI, 86% for the immature to total neutrophil ratio, 64% for C-reactive protein and 37% for the total white blood cell count. The corresponding specificity amounted to 97%, 85%, 85% and 86%, respectively. E-α1PI increases preceded elevations of C-reactive protein by 18 h. Like C-reactive protein, E-α1PI levels did not distinguish between bloodstream infection and non-bacterial inflammatory responses. Results of E-α1PI became available within 1 h of collection and usually 2–3 h before manual leucocyte counts. Conclusion Determination of neutrophil elastase α1-proteinase inhibitor levels yields diagnostic advantages comparable to those of manual differential counts but provide faster turnaround times. Received: 16 February 2000 / Accepted: 8 March 2000