Late-onset neutropenia in very low birthweight infants

AIM: To evaluate the incidence and duration of late-onset neutropenia (defined as an absolute neutrophil count (ANC) <1500 mm(-3) at a postnatal age of >3 wk) in a population of infants with birthweight <2000 g, and to determine whether copper deficiency, a possible cause of both anemia and neutropenia, may be associated with this complication. METHODS: Complete blood cell count and differential were assessed in 247 low (LBW) and very low birthweight (VLBW) infants who were discharged after 3 wk of life. In neutropenic infants plasma copper and ceruloplasmin levels were also measured. RESULTS: Late-onset neutropenia was detected in 11 out of 147 VLBW infants (7.5%) and in 7 out of 127 LBW infants (5.5%). A neutrophil count of <1000 mm(-3) was observed in 14 infants (5.1%). A significantly lower gestational age was found in neutropenic infants compared with non-neutropenic infants. In neutropenic infants ANCs were significantly correlated with hemoglobin and hematocrit. In addition, a significant negative correlation was found between neutrophil and reticulocyte counts. Plasma copper concentration was significantly correlated with birthweight. Oral copper sulfate was administered to infants with plasma copper concentration <50 microg dl(-1), and did not seem to affect ANC, hemoglobin, hematocrit or reticulocyte counts. CONCLUSION: Late-onset neutropenia appears to be a benign condition that is not associated with any particular complication and does not require specific treatment. Reference ranges after the early neonatal period and during the first few months of life in LBW and VLBW infants should probably be set at lower values.     

Transfusion-associated fall in platelet count in very low birthweight infants

Abstract Thirty-three infants with a birthweight of less than 1500 g were investigated retrospectively for the incidence and aetiology of thrombocytopenia occurring during the first week of life. The platelet count fell below 100 × 10⁹/l in 16 infants (48%). There was a moderately strong inverse correlation between the platelet count at its nadir during the first week or the first value below 100 × 10⁹/l and the percentage of blood volume transfused prior to this ( r =−0.61; P < 0.0001). When the platelet count was expressed as a percentage of the initial count the correlation was −0.74 ( P < 0.0001). The results were not affected by the elimination of the 10 infants with clinical conditions regarded as a probable cause of thrombocytopenia. The fitted least-squares regression line suggests that a transfusion equal to 10% of the blood volume on average reduced the platelet count by 19 × 10⁹/l or by 7% in these very low birthweight infants during the first week of life.     

Effect of recombinant human erythropoietin on transfusion needs in preterm infants

OBJECTIVE: To study the efficacy, safety and cost effectiveness of recombinant human erythropoietin (r-HuEPO) in reducing erythrocyte transfusion needs in very low birthweight (VLBW) infants. METHODS: We conducted a non-blind randomized controlled trial and assigned 100 VLBW infants, less than 33 weeks gestation, to receive either r-HuEPO 750 U/kg per week subcutaneously from day 5 to day 40 or no erythropoietin (EPO). Infants received oral iron 3-6 mg/kg per day from day 10. Transfusion needs were analysed for all enrolled infants and in five weight subgroups: birthweight of less than 600 g, 600-799 g, 800-999 g, 1000-1199 g and infants more than 1200 g. RESULTS: VLBW infants on r-HuEPO attained higher reticulocyte counts and haematocrit than control infants but the mean number of transfusions and volume of erythrocyte transfused per infant were not statistically different. Of infants 800-999 g at birth, the mean number of transfusions per infant was 2.1 compared with 3.5 transfusions per control infant (P = 0.04). Volume of erythrocytes transfused was 34.9 +/- 32.1 mL/kg in r-HuEPO-treated infants and 56.6 +/- 25.8 mL/kg in control infants (P = 0.03). The cost per patient for transfusion and EPO was S$388 for r-HuEPO recipient and S$438 for control infant. Blood pressure, neutrophil count, platelet count and complications of prematurity were not significantly different in both groups of VLBW infants. CONCLUSION: r-HuEPO at 750 U/kg per week stimulates erythropoiesis in VLBW infants but significantly reduces the need for erythrocyte transfusion only in infants weighing 800-999 g at birth.     

Determination of Serum Unbound Bilirubin for Prediction of Kernicterus in Low Birthweight infants

Serum unbound bilirubin concentrations (UBC) and serum total bilirubin concentrations (TBC) were measured serially in 138 low birthweight (LBW) infants treated with phototherapy for non-hemolytic hyperbilirubinemia. We attempted to assign the suitable critical UBC levels for predicting bilirubin encephalopathy into two different birthweight groups: a very low birthweight (VLBW) group (birthweight < 1,500 g) and an LBW group (birthweight between 1,500 g and 2,499 g). Twelve infants were diagnosed as 'at risk' for kernicterus, of whom 11 had signs of acute bilirubin encephalopathy and exchange transfusion. One VLBW infant had neurological sequelae at a 3 year follow-up, although exchange transfusion was not carried out because of low TBC.
Sensitivity and specificity for predicting kernicterus were calculated at different UBC levels between 0.6μg/dl and 1.5μg/dl and TBC levels between 8 mg/dl and 26 mg/dl. The receiver-operating characteristic (ROC) curves plotted for UBC as a predictor of kernicterus were clearly shifted up and to the left compared with the curves for TBC in the VLBW and LBW groups. Thus, the UBC measurement may well provide a more rational basis for evaluating the risk of kernicterus in LBW infants. The optimal cut-off points were derived from these curves. In the VLBW group, the sensitivity was 100% and the specificity was 96% for a UBC of 0.8μg/dl, and 80% and 64% for a TBC of 11 mg/dl. In the LBW group, the sensitivity was 100% and the specificity was 98% for a UBC of 1.0μg/dl and 71% and 78% for a TBC of 16 mg/dl. These results suggest that UBC determination is more suitable for predicting kernicterus than TBC in LBW infants with non-hemolytic hyperbilirubinemia.     

Neutropenia in antibody-deficient patients under IVIG replacement therapy

Patients with antibody deficiencies are more prone to develop acute neutropenic episodes even during immunoglobulin replacement. The aims of this study were to evaluate the presence of acute neutropenia in 42 patients with primary antibody immunodeficiencies, currently receiving intravenous immunoglobulin (IVIG), and to describe the clinical and laboratory findings during neutropenic episodes. Of all patients, 10 (23.8%) presented acute neutropenia (absolute neutrophil count <1500 cells/mm³) during follow up (mean of 6.4 yr). The absolute neutrophil count ranged from 71 to 1488 cells/mm³. Neutropenia was not clearly associated with antibiotic prophylactic therapy or immunoglobulin levels, while infections were associated with neutropenia in the majority of episodes. Most acute neutropenia episodes were mild or moderate, except in CVID patients who present more severe neutropenia. Although IVIG may have contributed to reducing the severity of neutropenia, it does not prevent its occurrence in all patients. In conclusion, primary immunodeficient patients, even submitted to IVIG replacement therapy, must be regularly evaluated for neutropenia in order to minimize the risk of infections and its appropriate approach.     

Effect of breastfeeding and morbidity on the development of low birthweight term babies in Brazil

Low birthweight (LBW) occurs in 17% of births in developing countries and many of them are full term. The subsequent development of LBW term infants is poorer than higher birthweight children and more likely to be affected by poor social circumstances. We investigated the effects of morbidity and breastfeeding on the development of these LBW term infants. Two parallel cohorts ( n = 131 + 131) of LBW term (1500-2499 g) and higher birthweight (3000–3499 g) infants were recruited from six maternity centers in northeast Brazil. The longitudinal prevalence of morbidity and the frequency of breastfeeding over the first 6 mo of life were assessed. The infants' development was assessed on the Bay ley Scales at 6 and 12 mo, and we previously reported that the low birthweight group had lower scores than the higher birthweight group. Hospitalizations in the first 6 mo were negatively associated with 6-mo and 12-mo Bayley scores in both groups. Among LBW infants, but not higher birthweight infants, there were significant associations between the prevalence of diarrhea and mental and motor development at 6 mo and mental development at 12 mo. Breastfeeding frequency in the first 4 wk of life was positively associated with mental development in both birthweight groups at 6 mo but not at 12 mo. Breastfeeding beyond 4 wk was not associated with the children's development. We conclude that low birthweight infants are especially vulnerable to the effects of diarrhea, and the greater frequency and differential effect of diarrhea partly explains their poorer development.     

Exclusively breastfed, low birthweight term infants do not need supplemental water

Breast milk intake, urine volume and urine-specific gravity (USG) of exclusively breastfed, low birthweight (LBW) term male infants in Honduras were measured during 8-h periods at 2 (n = 59) and 8 (n = 68) wk of age. Ambient temperature was 22-36 °C and relative humidity was 37-86%. Maximum USG ranged from 1.001 to 1.012, all within normal limits. Conclusions: We conclude that supplemental water is not required for exclusively breastfed, LBW term infants, even in hot conditions.     

Severe thrombocytopenia in extremely low birthweight infants with systemic candidiasis

The clinical, haematological and microbiological features of 12 extremely low birthweight (ELBW) infants with Candida infection were compared with 36 gestational-age and birthweight matched controls who experienced 42 episodes of bacterial septicaemia. Thrombocytopenia was the feature observed most commonly, occurring in 12 of 12 study infants and 23 of 42 controls ( P = 0.004). Minimum platelet counts were below 50 x 10⁹/L in 11 of 12 study patients compared with seven of 42 controls ( P < 0.0001). Severe thrombocytopenia may be a useful indicator of systemic Candida infection in ELBW infants.     

Acute Increase in Serum Tonicity Following Exchange Transfusion

ABSTRACT. We analysed the data of difference in serum sodium (DIFNA) and glucose (DIFGLU) concentrations and difference in serum tonicity (DIFTON) following exchange transfusion (ET) with CPD blood during 122 consecutive procedures performed in 82 newborn infants. Mean (± SE) gestational age (GA) was 30.8 ± 0.45 weeks, mean birthweight was 1568.6 ± 81.4 g, and mean age at time of ET (AGEH) was 60.6 ± 4.3 h. Following the ET, mean serum sodium concentration increased in 110 cases, by 5.4 ± 0.7 mmol/1, and the mean DIFTON rose by 14.6 ± 1.46 mOsm/kg H₂O. Mean DIFGLU rose in 111 cases by 3.8 ± 0.3 mmol/1. Significant correlations were found between DIFNA and AGEH (p<0.02), and between DIFTON and AGEH (p<0.02). ET performed < 48 h after birth produced higher DIFTON values than later transfusions (21.2 vs. 8.2 mOsm/kg H₂O, p<0.001) particularly in the VLBW infants (31.1 in < 28 weeks vs. 15.1 mOsm/kg H₂O in >28 weeks). VLBW neonates appear to be at greatest risk of developing extreme increments in serum tonicity following ET performed within the first 48 h of life.     

Plasma thrombomodulin level in very low birthweight infants at birth

Objective: Plasma soluble thrombomodulin level reflects endothelial damage. The plasma thrombomodulin level at birth is increased in asphyxiated full-term infants. There is no report of plasma thrombomodulin level in premature infants. To determine the thrombomodulin level in premature infants and whether it might reflect endothelial damage, we examined the plasma thrombomodulin level in very low birthweight (VLBW) infants at birth. Methods: Forty-five VLBW infants, of whom 14 had perinatal asphyxia complications, were recruited. As a control, 50 full-term infants wimout complications were also studied. Plasma thrombomodulin concentration, pH, base deficit, serum creatinine and D-dimer concentration, platelet count and fibrinogen concentration were measured within 1 hour after birth. Results: There were significant differences in plasma pH, creatinine concentration, platelet count, antithrombin in activity and D-dimer concentration between VLBW infants and full-term infants. Plasma thrombomodulin concentration (39. 0 (16. 6–93. 7) vs 27. 0 (16. 6–39. 1) μg/L, p < 0. 0001) and plasma taombomodulin-to-serum creatinine ratio (0. 82 (0. 19–2. 65) vs 0. 47 (0. 24–0. 70) μg/μmol, p < 0. 0001) were significantly higher in VLBW infants than those in full-term infants. By univariate analyses for all neonates, there were significant relations between plasma thrombomodulin concentration and gestational age, birthweight, plasma pH, creatinine concentration, platelet count and antithrombin in activity. A stepwise multiple linear regression model using the above variables as dependent factors showed only birthweight contributed significantly to plasma thrombomodulin concentration (plasma thrombomodulin concentration (μg/1) = 45. 677–0. 006 (birthweight; g), r²= 0. 323, p < 0. 0001, n= 94). Plasma thrombomodulin concentration and plasma thrombomodulin-to -serum creatinine ratio in VLBW infants with asphyxia were higher than in those without asphyxia, but not significantly different (43. 2 ± 17. 7 vs 38. 3 ± 8. 5 μg/1 and 0. 92 ± 0. 60 vs 0. 83 ± 0. 37 μg/μmol). Conclusion: Plasma thrombomodulin level in VLBW infants shows a high value at birth, and we consider the main factor responsible for this elevation may be endothelial damage or low clearance rate of thrombomodulin, which may be related to early gestational age.     

CRITICAL VITAMINS FOR LOW BIRTHWEIGHT INFANTS

Orzalesi, M. and Colarizi, P. (Department of Child Health, University of Sassari and the Department of Paediatrics, University of Rome, Italy). Critical vitamins for low birthweight infants. Acta Paediatr Scand, Suppl. 296: 00, 1982.—All vitamins are "critical" by definition for the growing infant. However, some of them are particularly relevant to the preterm or low birthweight (LBW) infant in whom a deficiency can occur more frequently than in a full-term newborn. In LBW infants vitamin deficiency may develop due to (1) low body stores at birth, (2) low intake, (3) limited absorption, (4) increased need or utilization, (5) presence of certain clinical conditions. The first reason concerns all lipid-soluble vitamins, and particularly vitamin E and K, which cross the placenta with some difficulty. Among hydro-soluble vitamins, cord-blood levels of vitamin B₆ have been shown to be abnormally low in preterm infants. Low intake can occur because of low vitamin levels in milk or because of delayed and/or insufficient feeding. Limited intestinal absorption of vitamins in LBW infants has only been demonstrated for vitamin E and folic acid. The rapid post-natal growth may lead to increased vitamin utilization. In some clinical conditions particularly high intakes of certain vitamins are indicated. In our opinion, the really "critical" vitamins in LBW infants are vitamin D, E, K and folic acid, for which routine supplementation can be recommended, and possibly vitamins C and B₆ under special circumstances.     

Selective improvement in cognitive test scores of extremely low birthweight infants aged between 2 and 5 years

Abstract The cognitive development at 2 and 5 years of a cohort of extremely low birthweight (ELBW) children (birthweight 500-999 g) was compared with that of cohorts of larger very low birthweight (VLBW) children (birthweight 1000-1500 g) and normal birthweight (NBW) children (birthweight > 2500 g) to determine whether the improvements in cognitive function of ELBW infants between 2 and 5 years are apparent or real.
At 2 years of age, ELBW children had a mean Mental Developmental Index (MDI) on the Bayley Scales of 90.4, significantly lower than the means of 100.3 for the larger VLBW children ( P = 0.006), and 107.8 for the NBW children ( P = 0.0002). However by 5 years the mean scores on the Wechsler Preschool and Primary Scales of Intelligence (WPPSI) full-scale for the ELBW and larger VLBW children were virtually identical (105.9 and 106.0 respectively)—but still lower than the mean WPPSI full-scale of 114.6 for the NBW children. After standardizing the MDI and WPPSI scores relative to the NBW children, the ELBW children improved between 2 and 5 years (paired t -test, t = 3.2, P = 0.004) whereas the larger VLBW infants did not.
We postulate that ELBW children require more time than larger VLBW children after birth to compensate for perinatal and other stresses, and that developmental delay at 2 years may not always persist to 5 years.     

Bioavailability of Urea Nitrogen for the Low Birthweight Infant

ABSTRACT. Previous studies have demonstrated increased retention (40%) of dietary urea nitrogen by term infants recovering from infection compared to healthy infants (13%), possibly due to a higher requirement for nitrogen. Since low birthweight infants also have a high requirement for nitrogen, the bioavailability of urea nitrogen was investigated in low birthweight infants using ¹⁵N, ¹⁵N-urea. Four low birthweight infants (gestational age = 30 ±2.2 weeks [mean ± SD, birthweight = 1.4 ±0.3 kg) were fed formula enriched with ¹⁵N, ¹⁵N-urea. Metabolic balance studies (72 hours) were performed with urine and fecal collections. Nitrogen was quantitated by Kjeldahl analysis and ¹⁵N, ¹⁵N-urea by gas chromatography/mass spectrometry. Mean nitrogen intake was 489 ± 32 mg/kg/d, with 75 % nitrogen absorption and 62% nitrogen retention. Maximum urinary enrichment was 8%. Cumulative ¹⁵N, ¹⁵N-urea excretion was 72%, resulting in 28% retention. Thus the bioavailability of urea nitrogen for low birthweight infants appears to be intermediate between compromised and normal term infants.     

Chronic lung disease in very low birthweight infants: A 5-year review

To determine the incidence, clinical spectrum and outcome of very low birthweight (VLBW) infants with chronic lung disease (CLD), and evaluate associated factors.

Methodology:

Retrospective review of 265 VLBW infants managed in the NICU from January 1988 to December 1992.

Results:

The overall neonatal survival rate for VLBW infants was 83%. Sixty-five (25%) infants had CLD, of whom 42% had severe CLD. Mortality in infants with CLD was 11%. In contrast with infants without CLD, CLD infants had significantly higher risk of adverse neurodevelopment with cerebral palsy documented in 13.5% and functional disability recorded in 34.6% at 2 years corrected age. Factors associated with the development of CLD included; decreasing birthweight (OR 0.98, Cl 0.97–0.99), septicaemia (OR 4.96, Cl 1.57–15.65), necrotizing enterocolitis (OR 119.07, Cl 4.98–2845.04), hyaline membrane disease (OR 5.34, Cl 1.83–15.55), patent ductus arteriosus (OR 4.46, CI 1.75–11.36) and increasing fraction of inspired oxygen concentration in the first week of life (OR 1.09, Cl 1.04–1.14).

Conclusions:

Chronic lung disease occurs frequently in VLBW infants and is associated with a high incidence of adverse neurodevelopment. Further studies to clarify the role of non-respiratory factors such as patent ductus arteriosus (PDA) and sepsis in the pathogenesis of CLD may reduce the incidence or prevent the development of CLD in these preterm infants.     

A national study of risk factors associated with mortality in very low birthweight infants in the Malaysian neonatal intensive care units

To determine the risk factors associated with mortality in very low birthweight (VLBW) infants admitted to the neonatal intensive care units (NIUC) in Malaysia.

Method:

A prospective observational study of outcome of all VLBW infants born between 1 January 1993 and 30 June 1993 and admitted to the NICU.

Results:

Data of 868 VLBW neonates from 18 centres in Malaysia were collected. Their mean birthweight was 1223 g (95% confidence intervals: 1208–1238 g). Thirty-seven point four per cent (325/868) of these infants died before discharge. After exclusion of all infants with congenital anomalies ( n =66, and nine of them also had incomplete records) and incomplete records ( n =82), stepwise logistic regression analysis of the remaining 720 infants showed that the risk factors that were significantly associated with increased mortality before discharge were: delivery in district hospitals, Chinese race, lower birthweight, lower gestation age, persistent pulmonary hypertension of the newborn, pulmonary airleak, necrotizing enterocolitis of stage 2 or 3, confirmed sepsis, hypotension, hypothermia, acute renal failure, intermittent positive pressure ventilation, and umbilical arterial catheterization. Factors that were significantly associated with lower risk of mortality were: use of antenatal steroid, oxygen therapy, surfactant therapy and blood transfusion.

Conclusion:

The mortality of VLBW infants admitted to the Malaysian NICU was high and was also associated with a number of preventable risk factors.     

Prolonged low-dose indomethacin therapy for patent ductus arteriosus in very low birthweight infants

To determine the efficacy and side-effects of prolonged low-dose indomethacin therapy in very low birthweight (VLBW; <1500 g) infants with a haemodynamically significant patent ductus arteriosus (hsPDA).

Methodology:

Very low birthweight infants admitted over a 16 month period were studied (6 months, retrospectively and 10 months, prospectively). Cross-sectional and M-Mode echocardiograms with pulsed-wave and colour Doppler were performed to assess the significance of ductal patency.

Results:

Forty-one (28%) of 148 VLBW infants were diagnosed to have hsPDA. Indomethacin therapy was successful in 90% after the first course, increasing to 95% after the second course. The recurrence rate after the first course was 3%. Minor and transient complications included oliguria, urea retention, hyponatraemia and thrombocytopenia. Although three infants had focal bowel perforation and the fourth had bowel perforation associated with necrotizing enterocolitis, the incidence of gastrointenstinal pathology was not significantly different from infants without hsPDA and not given indomethacin.

Conclusions:

Very low birthweight infants with hsPDA have a high response rate and low recurrence rate to prolonged lowdose indomethacin therapy. Side-effects were mild and transient. However, it is prudent to be cautious when administering indomethacin in critically ill infants <1000 g with hsPDA who manifest clinical features of bowel ischaemia.     

Oxygenation, Heart Rate and Temperature in Very Low Birthweight Infants during Skin-to-Skin Contact with Their Mothers

ABSTRACT. Fourteen very low birthweight infants were studied positioned either prone horizontal or skin-to-skin at 60 degree tilt between the mother's breasts. Heart rate, skin temperature and oxygenation by transcutaneous Po₂ and pulse oximetry were measured. Nine of the infants had normal lungs when studied. These infants showed no change in tcPo₂, or oxygen saturation but heart rate increased significantly by a mean of 6.5 beats per min during skin-to-skin contact. Five infants with chronic lung disease, including two on nasal catheter oxygen, showed a significant 1.0 kPa rise in tcPo₂ during skin-to-skin contact. Back skin temperature was well maintained during skin-to-skin contact with the room temperature at 26 to 29°C. None of the infants had a significant apnoea or bradycardia during the study. Stable very low birthweight infants can enjoy such close contact with their mothers and the tilted position may improve pulmonary function in some cases.     

Breast milk from mothers of very low birthweight infants: variability in fat and protein content

While breast milk appears to be superior to formula for the development of very low birthweight (VLBW) infants, it is supplemented to meet the metabolic demands of the rapidly growing premature infant. To estimate the nutritional variability of breast milk from mothers of VLBW infants, protein (bicinchoninic acid method) and fat content (creamatocrit) were measured in breast-milk spot samples from mothers of 20 VLBW infants, collected 4 times a day during the first 4 wk of lactation. Protein content (median 1.9 g dl(-1), range 1.1-3.5 g dl(-1)) and fat content (3.8/1.0-14.6 g dl(-1)) were highly variable and lacked a normal distribution over all samples and in individual women's milk. There was only a weak correlation between fat and protein (rs=0.416, p < 0.001). Fat but not protein was lower in morning samples than in samples collected later in the day (p < 0.001). Protein but not fat content decreased during the weeks of lactation (rs =-0.446, p < 0.001). No impact of the baby's gestational age was observed. CONCLUSION: The fat and protein content of breast milk from mothers of VLBW infants is highly variable, calling into question the clinical feasibility of individualized supplementation of breast milk for VLBW infants based on spot sample measurements.     

Two Siblings with Autoimmune Neutropenia of Infancy

We report two siblings with autoimmune neutropenia of infancy. Patient 1 was hospitalized for viral gastroenteritis at 5 months of age, when his absolute neutrophil count was 684/mm³. Absolute neutrophil counts ranging from 0 to 930/mm³ continued but normalized spontaneously at 25 months of age. Patient 2, a younger brother of patient 1, had prolonged high grade fever at 5 months, when his absolute neutrophil count was 138/mm³. Absolute neutrophil counts ranging from 96 to 1,078/mm³ continued for the following 9 months. Antineutrophil antibodies were detected in the patients' sera. Our cases are siblings and each case was independently affected, since the diagnoses were made at 5 months of age and the interval between the diagnoses was 23 months. Autoimmune neutropenia of infancy is comparatively rare, so that we think that the disease in these siblings was due to a genetic abnormality.     

Surgery is safe in very low birthweight infants with necrotizing enterocolitis

The aim of this study was to determine how the operative event itself affects very low birthweight (VLBW) infants (< 1500 g) with necrotizing enterocolitis (NEC) undergoing surgery, and to try to identify preventable factors leading to perioperative morbidity and mortality. Eighty-five VLBW infants developed NEC during a 6-year period; 34 of those required emergent celiotomies. Data were collected retrospectively from hospital charts available on 33 infants. Birthweight ranged from 566 g to 1415 g (mean +/- SD: 961+/-262 g) and gestational age from 24 to 34 wk (28+/-3.2 wk). Thirty infants had been fed premature formula (first feed at 5+/-3.6 d) prior to the onset of symptoms and three had not been fed at all. Age at NEC symptoms was 19+/-15 d. Infants < 1000 g developed NEC much longer after the first feed compared to infants > 1000 g (p < 0.002; t-test). In 42% of the children, intraoperative blood pressure fell at least 20% from the preoperative value. Body temperature dropped from a preoperative 36.5+/-0.340 degrees C to 35.5+/-1.20 degrees C (p < 0.005), although in all children two or more heating devices were employed in the operating room. All infants survived the procedure. Six infants with pannecrosis died within 72 h of the operative event. In an appropriate setting, operative intervention under general anesthesia is well tolerated by VLBW infants with NEC. Since hypothermia was a major problem, the authors have modified their approach and now no longer transport these infants to the operating room. Instead, these infants are operated upon in the neonatal intensive care unit, directly on an infant radiant warmer system.