Rickets in a very low birth weight infant

A report on a case of rickets in a very low birth weight infant (VLBWI) is presented. The infant had no high-risk factors for rickets and was fed a specialized preterm formula with vitamin D supplementation (200 IU daily) by 10 days of age. Feeds were advanced so that an enteral intake of 120 cal/kg/day was achieved by the 20th day of life. Mean calcium, phosphorus, and vitamin D intakes between the 20th and 61st days of life were 185 mg/kg/day, 93 mg/kg/day, and 367 IU/day, respectively. On the 62nd day of life, a diagnosis of rickets was made, and a nutrient balance study was performed. Urinary calcium excretion was low (1.3 mg/kg/day), suggesting calcium deficiency. However, retention of calcium (127 mg/kg/day) and phosphorus (76 mg/kg/day) was occurring at intrauterine rates. Thus, while calcium absorption was adequate at 10 weeks of age, the same was not true earlier in life. We suggest that there is a limiting role of calcium absorption on bone mineralization during early life in the VLBWI.     

Fungal colonization in the very low birth weight infant

In the neonate, fungal infections result in significant morbidity and mortality. For very low birth weight (less than 1,500 g) infants, we prospectively determined the fungal colonization rate to be 26.7%. In one third of infants with fungal colonies, mucocutaneous candidiasis developed, and in 7.7%, systemic disease developed. Two thirds of the infants had colonies in the first week of life. This colonization was probably acquired during labor and delivery, because those infants who had colonization were more often delivered vaginally than by cesarean section. Early colonization, commonly from the gastrointestinal or respiratory tract, featured Candida albicans and Candida tropicalis. Late colonization, occurring after 2 weeks of life (15.0% of patients), was more likely to be cutaneous and was associated with either Candida parapsilosis or such poor growth that the organism could not be identified. Infants with colonization only rarely had budding yeasts (6.1%), whereas more than half of the infants with either a urinalysis showing budding yeasts or a urine culture growing fungi had invasive disease. Fungal contamination was not found on either thoracotomy tubes or catheter tips. In the low birth weight infant, fungal colonization represents a significant risk factor for cutaneous or systemic candidiasis in these infants.     

极低出生体重儿并发脑室内出血的诊断和治疗

极低出生体重儿 (ＶＬＢＷＩ)并发脑室周围 脑室内出血(ｐｅｒｉｖｅｎｔｒｉｃｕｌａｒｈｅｍｏｒｒｈａｇｅ Ｉｎｔｒａｖｅｎｔｒｉｃｕｌａｒｈｅｍｏｒｒｈａｇｅ ,ＰＶＨ ＩＶＨ)较为常见。根据头颅系列超声检查 ,ＰＶＨ ＩＶＨ发病率约为 40 %～ 5 0 % ,随胎龄及体重降低发病率增加。胎龄 <32周的早产儿约 30 %～ 35 %发病 ,<2 8周者 ,发病率超过 5 0 % ;体重 <5 0 0 ｇ～ 75 0 ｇ者 ,发病率为 6 0 %～70 % ,10 0 0 ｇ～ 15 0 0 ｇ者为 10 %～ 2 0 %。ＰＶＨ ＩＶＨ的发生 ,主要由于ＶＬＢＷＩ室管膜下生发层基质 (尾状核头部脑室周…     

Holding the very low birth weight infant: skin-to-skin techniques

Skin-to-skin holding has been reported as a valuable intervention for preterm infants for over a decade. However, many neonatal intensive care units are not practicing this therapy and cite lack of protocols and techniques as a barrier. This article describes in detail the nursing considerations and techniques involved to successfully implement skin-to-skin holding for very low birth weight, technology-dependent infants. NICU protocols can be derived from this article.     

极低出生体重儿高频振荡通气

高频通气(HFV)用于新生儿呼吸衰竭的治疗已20余年,积累了许多实验资料及临床经验,检索到的文献达1300余篇[1].由于通气策略的不断改进,早期HFV常作为对新生儿严重呼吸衰竭常规呼吸机治疗失败后的营救性治疗.极低出生体重(VLBW)儿行常规通气(CV)治疗呼吸衰竭时易产生多种急、慢性肺部并发症,影响治疗效果及预后.近年来在用高频振荡通气(HFOV)减少肺损伤和对肺采取保护性治疗策略方面进行了探讨,简述如下. 1 HFV的主要种类及其作用 HFV有三种类型:即高频喷射通气(HFJV)(以Bunnell公司的Lifepulse为代表),目前已较少应用;高频气流阻断(HFFI)(以Infransouics公司的Infant star为代表);HFOV(以Sensormedics公司的Sensormedics 3100A为代表).其他尚有德国Drger公司的Babylog 8000及英国的SLE 200等.前述三种呼吸机内部功能不完全相同,但通气容量均近于或小于死腔气容量.HFOV为目前广泛应用的一类,Infant star虽以HFFI形式进行通气,由于以呼气为主动,其作用也可理解为HFOV.Sensormedics 3100A通气时设高频率,吸、呼比值为1∶ 2,而Infant star行HFV时除设置高频率外尚需与CV联合应用,设2～5/min,间歇强制通气(IMV).     

Insulin pump therapy in the very low birth weight infant

Ten critically ill, very low birth weight infants less than 30 weeks' gestation were treated with exogenous insulin administered through a continuous insulin infusion pump (Betatron II, Cardiac Pacemaker, Inc). Infants were hyperglycemic to dextrose infusions greater than 6 mg/kg/min. The blood glucose concentration became normal in all infants within two to four hours, with varying requirements for continued insulin treatment. Tolerance to intravenous dextrose increased from a mean of 7.4 mg/kg/min to 11.2 mg/kg/min with glycosuria. Energy intake increased from 49.5 calories/kg/d prior to insulin pump therapy to 70.4 calories/kg/d afterward (P less than .01) with weight gain changed from -23 g/d to +13 g/d (P less than .01). One unexpected observation was the apparent normalization of blood glucose homeostasis on higher dextrose doses among some infants after only one three- to six-hour treatment with insulin. The continuous insulin infusion pump is a flexible tool that allows insulin infusion rates to be changed as dictated by blood glucose values without altering other parenteral infusions.     

Cerebrospinal fluid values in the very low birth weight infant

The cerebrospinal fluid values obtained in the first 12 weeks of life from 43 infants with birth weights of 1500 gm or less were analyzed to determine the ranges for leukocyte count and chemistry values. All these neonates had birth weights appropriate for gestational age, negative cerebrospinal fluid culture for bacteria, and no evidence of intracranial bleeding by head ultrasound examination. The mean birth weight was 1002 gm (range 550 to 1500 gm), and mean gestational age was 27 weeks (range 24 to 33 weeks). The mean cerebrospinal fluid leukocyte count was 5 cells/mm3 (range 0 to 44 cells/mm3); leukocyte differential was 7% polymorphonuclear leukocytes (range up to 66%) and 85% mononuclear leukocytes (range 13% to 100%). Additional values included protein concentration, 142 mg/dl (range 45 to 370 mg/dl); and glucose, 60 mg/dl (range 29 to 217 mg/dl). Knowledge of these measurements should help in the interpretation of the cerebrospinal fluid values of the very low birth weight infant undergoing examination of a central nervous system disorder.     

The white cell ratio in the very low birth weight infant.

The purpose of this study was to assess the usefulness of the white cell ratio of immature neutrophils (PMNs) to total (immature plus mature) PMNs as an indication of infection in the very small premature infant. We retrospectively reviewed the charts of 59 premature infants less than or equal to 1,250 g admitted to our Newborn Intensive Care Unit over a one-year period who had at least one white count determined. Twenty-three were born after rupture of membranes for greater than or equal to 24 hours (PROM), 47 had a one-minute Apgar score less than or equal to 6 and 31 had a five-minute Apgar scores less than or equal to 6, 38 had respiratory distress syndrome (RDS), and 4 had confirmed infection. Thirty-one of the infants had a ratio greater than or equal to .15 in the first day of life, a value which has been suggested in the literature as being abnormal and an indication to suspect sepsis. This ratio bore no statistical relationship to PROM, low Apgar scores, or RDS. We analyzed these same relationships using a ratio greater than or equal to .25, another ratio derived from data in the literature which has been said to suggest infection. No statistical correlation was found for low Apgars or RDS, but there was a significant relationship between PROM and attainment of a ratio greater than or equal to .25 (p less than .005). It is notable that 2 out of the 4 infants with infection had a ratio less than .15. We wish to cast doubt on the applicability of the currently defined WBC ratios in the literature as they apply to the infant with birth weight less than 1,250 g and emphasize the apparent effect of PROM as a factor upon these ratios.     

Ethical aspects in the care of very low birth weight infants

Advances in the neonatal intensive care (NIC) of the very low birth weight infant (VLBW) have given rise to important ethical questions. (1) Does every VLBW infant have the right to NIC? (2) Who should decide whether to treat? (3) How should resources be allocated for NIC? To play their part in answering these questions, paediatricians must become familiar with the principles of ethical reasoning. A distinction can be drawn between a human being and a human person on the basis of the possession of certain qualities, in the absence of which non-treatment may be justified. It will usually not be possible to make this distinction prospectively and hence it is not of much practical assistance as a criterion for decision making. Future disability of th infant can also be advanced as a reason for non-treatment, but it is not possible to know whether avoidance of disability makes it in the best interest of the infant to not be treated, and hence probable future disability is not per se an acceptable criterion for non-treatment. Pain and distress, however, is within the comprehension of decision makers and its avoidance may be an acceptable criterion for non-treatment (although in practice rarely a helpful one). The most useful criterion is one based on the ethics of resource allocation. Resources should be allocated in accordance with the ethical principles of justice and full beneficence. Criteria based on prognosis should be established to decide which VLBW infants should share in the finite resources directed to NIC.     

The relationship between placental and other perinatal risk factors for neurologic impairment in very low birth weight children

Placental abnormalities reflect antenatal disease processes that may interact with other perinatal risk factors to affect long-term outcome. We performed a nested case control analysis of placental and clinical risk factors associated with neurologic impairment (NI) at 20-mo corrected age (60 cases and 59 controls) using data collected in a prospective study of very low birth weight (less than 1500 g) infants born between 1983 and 1991. In a preliminary analysis we explored the relationship between clinical infection and histologic chorioamnionitis (CA). Only histologic CA with a fetal vascular response correlated with either clinical CA or early onset neonatal sepsis. We then assessed the relative contribution of the nine risk factors (four placental and five clinical) associated with NI at the univariate level by multiple logistic regression. Three risk factors were independent predictors of NI: severe cranial ultrasound abnormalities (odds ratio 13.6, 95% confidence intervals 4.5-66.7), multiple placental lesions (odds ratio 13.2, 95% confidence intervals 1.3-137.0), and oxygen dependence at 36 wk (odds ratio 4.2, 95% confidence intervals 1.2-14.6). Finally, a series of logistic regressions was conducted with the dependent variable changing as we moved back along the causal chain to explore the relationships between risk factors operating at different stages. This analysis suggested that antenatal variables that were not independent predictors of NI by multiple logistic regression exerted their effects through the following intermediate pathways: fetal grade 3 histologic CA via chorionic vessel thrombi, clinical CA via grade 3 villous edema, and grade 3 villous edema via severe cranial ultrasound abnormalities.     

极低出生体重儿支气管肺发育不良及其危险因素分析

目的 探讨极低出生体重儿(VLBWI)支气管肺发育不良(BPD)的发生率和高危因素.方法 回顾性分析我院新生儿重症监护室在2006年8月至2009年2月期间,住院28 d以上VLBWI 122例临床资料,以BPD发生与否分组,采用SPSS 10.0统计软件包进行BPD危险因素分析.结果 25例发生BPD,发生率20.5%,在胎龄<28周的超未成熟儿中BPD发生率70%.BPD主要发生在胎龄<30周、出生体质量<1250 g的早产儿.通过16个单因素分析发现,胎龄、出生体质量、窒息、机械通气、持续气道正压通气、持续气道正压通气时间、呼吸衰竭、新生儿呼吸窘迫综合征、肺表面活性物质治疗、重症肺炎、医院感染等11个因素有统计学意义,两组吸氧时间分别为(41.8±15.2)d和(5.0±9.8)d.通过对胎龄、出生体质量、窒息、机械通气、持续气道正压通气、持续气道正压通气时间、呼吸衰竭、新生儿呼吸窘迫综合征、重症肺炎、医院感染等10个发病因素进行Logistic回归分析,发现胎龄(OR 0.875,95%CI 0.790～0.968,P=0.001)和重症肺炎(OR 155.302,95%CI 8.944～2696.473,P=0.01)是BPD的最危险因素,具有统计学意义.结论 胎龄小和重症肺炎是BPD的高危因素.     

Thoracotomy for persistent bronchopleural fistula in the very low birth weight infant

Although conservative treatment is appropriate for most very low birth weight infants with bronchopleural fistulas, early surgical closure may improve survival in properly selected patients. We report our experience with successful surgical closure in 3 consecutive neonates weighing <800 g.     

极低及超低出生体重儿肺出血的影响因素及预后分析

目的 探讨极低及超低出生体重(出生体重≤1200g)早产儿肺出血的影响因素及预后.方法 回顾性分析2010年1月至2015年12月于中国医科大学附属盛京医院第二新生儿科住院、出生体重≤1200g、住院期间发生肺出血的极低及超低出生体重儿临床资料,同期住院、相同体重范围非肺出血早产儿作为对照组.比较两组母孕期及新生儿期特点,多元回归分析探讨肺出血影响因素,了解肺出血新生儿的近期预后.结果 肺出血新生儿(肺出血组)71例,对照组364例.肺出血发生于 3d 以内者57例(占80.3%),肺出血组胎龄(28.2±1.7)周、出生体重(936±192)g,均明显低于对照组[(29.5±2.1)周,(1033±134)g,t分别为4.776、-5.145,P<0.01].肺出血组呼吸窘迫综合征(RDS)(76.1%)、肺表面活性物质治疗(76.1%,其中≥2次使用率9.9%)、动脉导管未闭(PDA)(66.2%)比例均明显高于对照组[41.2%、30.8%(4.1%)和38.7%,χ2值分别为33.457、28.970(4.074)和32.798,P<0.05].肺出血组产前类固醇激素治疗率(21.1%)亦明显低于对照组(41.2%,χ2=10.177,P<0.01).多因素Logistic逐步回归分析显示,RDS(OR=3.739,95%CI 1.383-10.113,P<0.05)、PDA(OR=2.206,95%CI 1.205-4.093,P<0.05)及5 min Apgar评分<7(OR=2.851,95%CI 1.191-6.828)是肺出血的独立危险因素;出生体重大(OR=0.998,95%CI 0.996-1.000,P<0.05)及母孕期应用激素 (OR=0.432,95%CI 0.224-0.834,P<0.05)是肺出血的保护因素.肺出血组颅内出血、早产儿视网膜病及重度支气管肺发育不良发生率(16.9%、12.7%及18.3%)明显高于对照组(5.8%、4.4%及2.2%,χ2值分别为36.824、7.520及33.568,P<0.01).肺出血组病死率(49.3%)亦明显高于对照组(14.0%,χ2=46.634,P<0.01).结论 多种围生期因素与肺出血有关;预防早产及产前类固醇激素治疗有助于预防肺出血;肺出血新生儿不良预后发生率高.     

极低出生体重儿颅内出血危险因素的分析

目的：颅内出血是造成极低出生体重（VLBW）儿智力及运动障碍主要原因之一,了解其发病的危险因素、及早预防,可减少残疾、提高生存质量。方法研究169例极低出生体重儿,对产前因素及生后因素进行分析,采用SPSS12.0对数据进行卡方检验,有意义因素再进行logistic回归分析,得出回归方程。结果胎膜早破、1分钟Apgar评分≤7分、使用PS及呼吸机治疗、上机时间＞3 d、入院时PT＞20 s、生后1 d和2 d低钠血症及生后1 d pH值＜7.25为VLBW颅内出血危险因素。结论1分钟Apgar评分≤7分和使用呼吸机治疗是VLBW儿颅内出血的主要危险因素,而凝血功能和内环境紊乱均与缺氧窒息有关。因此,作好产前保健,减少窒息及生后合并症发生,有利于降低VLBW儿颅内出血发生率,提高患儿生存质量。 ［中国当代儿科杂志,2007,9（4）：297-300］