Apparent life threatening events in infants presenting to an emergency department

Objective: To describe the aetiology and outcome of apparent life threatening events (ALTE) presenting to an emergency department (ED), and to assess the value of an initial investigation protocol.

Design: A 12 month prospective study of infants under 1 year of age who presented to a children's hospital ED after an ALTE. A standardised history sheet and initial investigation protocol were used. All infants were admitted to hospital and followed up at six months.

Results: There were 65 infants recruited, median age 7 weeks. None had died at the time of writing. Diagnoses included gastro-oesophageal reflux n=17 (26%), pertussis, n=6 (9%), seizures, n=6 (9%), urinary tract infection (5), factitious illness (2), brain tumour, atrial tachycardia, persistent ductus arteriosus and opioid related apnoea. No diagnosis was reached in 15 cases (23%). Fifty seven (88%) had only one admission to hospital for ALTE. More serious diagnoses were associated with a presentation age over 2 months, abnormal initial clinical examination, and recurrent ALTE.

Conclusions: ALTEs presenting to the ED may remain as a single, unexplained event or be attributable to numerous causes, ranging from minor to serious. Knowledge of the commoner causes and factors associated with higher risk could result in a more targeted approach, improving the decision making process and benefiting both infants and parents.

     

Clinical and parasitological response of Plasmodium falciparum to chloroquine and sulfadoxine/pyrimethamine in rural Uganda

Following the WHO protocol for in-vivo tests in areas with intense transmission of uncomplicated falciparum malaria, a randomized comparison of the invivo efficacy of chloroquine alone, sulfadoxine/pyrimethamine alone, and their combined administration was carried out in the third quarter of 2001 in Kaberamaido District, northeastern Uganda. Malaria in the study area is hyper-endemic, with a high prevalence of Plasmodium falciparum. The patients were infants and young children with a median age of 15 months. Of the 117 originally enrolled patients, 104 had a complete follow-up with presentation at all scheduled examinations. In the chloroquine group (n = 42), 55% were classified as adequate clinical response, 26% as early treatment failure, and 19% as late clinical failure. In the sulfadoxine/pyrimethamine group (n = 30), the respective figures were 83%, 13% and 3%, and in the group with combined treatment (n = 32), 88%, 6% and 6%. In terms of clinical cure rate, speed of clinical relief and parasite clearance the combined treatment proved to be the most effective of the three drug regimens. In the patients with adequate clinical response, a significant post-therapeutic increase of the haematocrit was observed, which was particularly marked in patients who had also cleared their parasitaemia. Increase of the efficacy of chloroquine with age indicates the early development of semi-immunity in the study area, with conserved efficacy of chloroquine in semi-immune persons.     

Serial measurements increase the accuracy of laser Doppler assessment of burn wounds

Traditional methods of judging burn depth by clinical evaluation of the wound based on appearance and sensation remain in wide use but are subject to individual variation by examiner. In addition to the clinical difficulties with burn wound management, observer dependency of wound assessment complicates clinical trials of burn wound therapy. A laser Doppler flowmeter with a multichannel probe was used to measure burn wound perfusion as a tool to predict wound outcome. Serial measurement with laser Doppler flowmetry had an 88% specificity and a positive predictive value of 81% for identifying nonhealing wounds. These results suggest that laser Doppler flowmetry is a potentially useful tool for burn wound assessment.     

Pediatric risk of mortality scoring overestimates severity of illness in infants.

OBJECTIVE: To validate Pediatric Risk of Mortality (PRISM) scoring in infants and children admitted for intensive care. DESIGN: Validation cohort. SETTING: A five-bed pediatric ICU and three cots providing intensive care for surgical neonates, within a 159-bed tertiary care children's hospital. PATIENTS: All patients admitted for intensive care during an 18-month period, January 1990 to July 1991. METHODS: Admission (first 24 hrs) PRISM scoring was introduced as a routine procedure. Discretion was allowed in requesting arterial blood gas measurements and clotting studies. All other parameters were intended to be measured on all patients. MEASUREMENTS AND MAIN RESULTS: PRISM scores were obtained on 380 (88%) of 433 patients. Median age was 15 months. A complete PRISM score was obtained in 24% of cases and a score as intended (i.e., allowing discretionary omissions) was obtained in 56% of patients. Comparison of observed and predicted mortality rates using chi square goodness-of-fit tests showed a significantly better observed outcome for all patients (chi 2(5) = 12.04, p < .05). In-depth analysis indicates that the model works well for children (chi 2(5) = 1.80, p > .75), but that observed outcome is significantly better than predicted for infants (chi 2(5) = 17.46, p < .01). Underscoring of children is not the cause of this finding. CONCLUSIONS: In our center, PRISM scoring overestimates severity of illness in infants. PRISM scoring is not institutionally independent and therefore, at present, a comparison between units may not be justified. A reappraisal of the parameter ranges for infants is suggested.     

Audit of prenatal and postnatal diagnosis of isolated open spina bifida in three university hospitals in The Netherlands.

OBJECTIVE: To audit the current Dutch policy of prenatal detection of isolated open spina bifida based on offering detailed ultrasound examination only on indication. METHODS: A retrospective analysis of prenatally diagnosed isolated spina bifida cases and of newborns diagnosed with this condition was carried out in three university hospitals. The data were collected from databases and clinical records of the departments of prenatal diagnosis, obstetrics, neonatology, child neurology and neurosurgery of the three centers. RESULTS: Between January 1996 and December 1999, 88 cases of isolated open spina bifida were diagnosed prenatally by ultrasound investigation. Thirty-eight cases (43%) were diagnosed before the 24th week of gestation. Of these, 35 (92%) ended in termination of the pregnancy at the parents' request. Of the remaining 50 cases (57%) diagnosed after the 24th week of gestation, eight (16%) pregnancies were terminated beyond the legal limit for termination due to the severity of the condition. Of the 88 cases of isolated spina bifida, 25 infants (28%) were still alive at the age of 4 years. In the same audit period 112 newborn infants with isolated open spina bifida were admitted to the neonatology, child neurology, or neurosurgery ward of the three centers. Of these cases, 47 (42%) had been diagnosed prenatally and 65 (58%) were an unexpected finding at birth. In 24 infants (21%) surgical treatment was withheld because of the severity of the condition and predicted poor outcome, whereas the remaining 88 infants (79%) underwent surgical repair. CONCLUSION: The current practice in The Netherlands of offering ultrasound screening to high-risk patients only leads to the early detection of a minority of cases of spina bifida. Most cases are diagnosed either after the 24th week of gestation or they remain undiagnosed until after birth. When spina bifida is diagnosed before the 24th week of gestation the vast majority of parents opt for termination. In order to reduce the birth prevalence of spina bifida in The Netherlands the introduction of a policy of routine ultrasound screening should be considered.     

痉挛型双瘫的临床特征

目的：探讨痉挛型双瘫的临床特征,为脑功能的全面康复提供基础资料。方法：对５０ 例痉挛型双瘫患儿的临床资料进行回顾性分析。结果：５０ 例中３５ 例为早产儿（７０％）,高危因素依次为早产、低体重、缺氧、硬肿症、颅内出血;１５ 例为足月儿（３０％）,高危因素主要为窒息、缺氧缺血性脑病。５０ 例患儿运动神经功能异常,全部表现为骨盆带及下肢痉挛及由此所致的姿势异常,双上肢受累较轻。平均精细运动年龄１８．５ 个月,粗大运动年龄８．７５ 个月（Ｐ＜ ０．０１）。半数患儿同时合并斜视、语言发育迟缓和／ 或运动性构音障碍。结论：痉挛型双瘫的病因,运动神经系统表现具有特征性,对其正确的认识评价有助于康复计划的制订。     

Increased plasma concentrations of activin a predict intraventricular hemorrhage in preterm newborns

BACKGROUND: Intraventricular hemorrhage (IVH) is a major cause of neurologic disabilities in preterm newborns. We evaluated the use of plasma activin A concentrations to predict the development of perinatal IVH. METHODS: We measured nucleated erythrocyte (NRBC) counts, plasma activin A, hypoxanthine (Hyp), and xanthine (Xan) in arterial blood samples obtained from 53 preterm infants during the first hour after birth. Cerebral ultrasound was performed within 48 h of birth and repeated at 5- or 6-day intervals until the age of 4 weeks. RESULTS: Grade I or II IVH was detected during the first 10 days of life in 11 of 53 patients (21%). Activin A, Hyp, and Xan concentrations and NRBC counts were higher in preterm newborns who subsequently developed IVH than in those who did not (P<0.0001, except P=0.019 for Xan). Neonatal activin A was correlated (P<0.0001) with Hyp (r=0.95), Xan (r=0.90), and NRBC count (r=0.90) in newborns without later IVH and in those who developed IVH (Hyp, r=0.89, P=0.0002; Xan, r=0.95, P<0.0001; NRBC count, r=0.90, P=0.0002). At a cutoff of 0.8 microg/L activin A, the sensitivity and specificity were 100% [11 of 11; 95% confidence interval (CI), 71%-100%] and 93% (39 of 42; 95% CI, 81%-98%), and positive and negative predictive values were 79% (95% CI, 61%-100%) and 0% (95% CI, 0%-2%), respectively. The area under the ROC curve was 0.98. CONCLUSIONS: Activin A concentrations at birth are increased in preterm newborns who later develop IVH and may be useful for early identification of infants with hypoxic-ischemic brain insults who are at high risk for IVH.     

Predictive model for congenital muscular torticollis: analysis of 1021 infants with sonography

OBJECTIVE: To construct a predictive model to foretell congenital muscular torticollis (CMT) on the basis of clinical correlates. DESIGN: Correlation study. SETTING: Regional hospital. PARTICIPANTS: A consecutive series of 1021 newborn infants. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: Participants underwent portable ultrasonography to diagnose CMT. Significant clinical correlates were identified to construct a predictive model using the logistic regression model. RESULTS: Forty of 1021 infants were diagnosed with CMT using ultrasonography, yielding an overall incidence of 3.92%. Birth body length (odds ratio [OR]=1.38; 95% confidence interval [CI], 1.49-2.38), facial asymmetry (OR=21.75; 95% CI, 6.6-71.7), plagiocephaly (OR=22.3; 95% CI, 7.01-70.95), perineal trauma during delivery (OR=4.26; 95% CI, 1.25-14.52), and primiparity (OR=6.32; 95% CI, 2.34-17.04) were significant correlates. A predictive logistic regression model with the incorporation of these 4 correlates was developed. We used cross-validation with a receiver operating characteristic curve to validate the predictive model. CONCLUSIONS: Our study successfully developed a quantitative predictive model for estimating the risk of CMT on the basis of clinical correlates only. This model has good discriminative ability for classifying CMT and non-CMT by yielding acceptable values of false-negative and false-positive cases.     

The fetal transverse cerebellar diameter/abdominal circumference ratio: a gestational age-independent method of assessing fetal size

The relationship between the fetal TCD and the AC throughout pregnancy was investigated in a prospective, cross-sectional study of 700 well dated, normal pregnancies between 14 and 42 weeks of gestation and tested in 30 known SGA infants. Fetal measurements included the TCD, AC, BPD, HC, and FL. The TCD/AC ratio was calculated for each patient. Statistical analysis using linear regression and Student's t-test was performed. Strong correlation existed between gestational age and transcerebellar diameter (R2 = 0.9464), between gestational age and AC (R2 = 0.9685), and between TCD and AC (R2 = 0.9561). The TCD/AC ratio was normally distributed with a mean +/- SD of 13.69 +/- 0.94% (median, 13.71%). The 10th and 90th percentiles were 12.50% and 14.86%, respectively. The ratio remained constant throughout pregnancy with respect to gestational age (R2 = 0.0084). A TCD/AC ratio greater than the 90th percentile was present in 87% (26/30) known SGA infants. The TCD/AC ratio is a stable, gestational age-independent parameter that may be useful in the early detection of fetal growth abnormalities.     

Factors Related to Birth Transition Success of Late Preterm Infants

The purpose of this study was to determine the prevalence of, and clinical-epidemiological and demographic predictive factors for, birth transition success of late preterm infants. A retrospective, case-control chart review was used to compare the characteristics of successful and unsuccessful birth transition of late-preterm infants delivered in a large tertiary-care center. Categorical and numeric variables related to maternal, birth, and physiologic constructs were analyzed. Four predictor variables were associated with birth transition failure: labor (OR = .42, P = .014), 5-minute Apgar score (OR = 1.79, P = .003), gender (OR = .47, P =.043) and respiratory rate (OR = 2.08, P < .001). The overall classification rate for the model was 70.3%. Transition success and failure were accurately assigned at a rate of 66.7% and 74%, respectively. The primary implication of this research is that the absence of labor, male gender, low Apgar scoring, and tachypnea (>60) were identified as a risk factors for transition failure of late preterm infants.     

Frequency and Prediction of Abnormal Findings on Neuroimaging of Infants with Bulging Anterior Fontanelles

Objectives: This study sought to determine the frequency of clinically significant abnormal findings on neuroimaging using neurosonography (NS) in infants with bulging anterior fontanelles (BAFs) and to identify infants at high or low risk for clinically significant abnormal findings on neuroimaging. Methods: NS was performed in 45 consecutive infants with BAFs brought to the emergency department of a tertiary care hospital. NS reports were categorized as normal, clinically insignificant abnormal, or clinically significant abnormal. For each patient, demographic data, laboratory test results, and clinical diagnosis and outcome were obtained for analysis. Results: Eighteen febrile and 27 nonfebrile infants with BAFs were evaluated. Clinically significant abnormal findings on NS were noted in 16 of 45 patients (36%), five of whom were febrile and 11 of whom were nonfebrile. Brain edema resulting from infection was the most common finding on NS. Univariate analysis indicated that age younger than two months in febrile patients and abnormal findings on neurologic examination in nonfebrile patients were significant clinical predictors for clinically significant abnormal findings on NS in infants with BAFs. Patients presenting with either of these clinical predictors were identified as high risk for abnormal findings on NS. Of the high-risk patients, 15 of 17 patients (88%) had clinically significant abnormal findings on NS, compared with one of 28 patients (4%) in the low-risk group. Conclusions: This study shows a 36% prevalence of clinically significant abnormal findings on NS in infants with BAFs. Emergent neuroimaging should be considered for infants who meet high-risk criteria: 1) febrile children younger than two months or 2) nonfebrile children with abnormal findings on neurologic examination.     

Serious Bacterial Infection in Recently Immunized Young Febrile Infants

Objective: The objective of this study was to investigate the prevalence of serious bacterial infection (SBI) in febrile infants without a source aged 6–12 weeks who have received immunizations in the preceding 72 hours. Methods: The authors conducted a medical record review of infants aged 6–12 weeks with a fever of ≥38.0°C presenting to the pediatric emergency department (ED) over 88 months. Infants were classified either as having received immunizations within the 72 hours preceding the ED visit (recent immunization [RI]) or as not having received immunizations during this time period (no recent immunization [NRI]). Primary outcome of an SBI was based on culture results; only patients with a minimum of blood and urine cultures were studied. Results: A total of 1,978 febrile infants were studied, of whom 213 (10.8%) had received RIs. The overall prevalence of definite SBI was 6.6% (95% confidence interval [CI] = 5.5 to 7.7). The prevalence of definite SBI in NRI infants was 7.0% (95% CI = 5.9 to 8.3) compared to 2.8% (95% CI = 0.6 to 5.1) in the RI infants. The prevalence of definite SBI in febrile infants vaccinated in the preceding 24 hours decreased to 0.6% (95% CI = 0 to 1.9). The prevalence of definite SBI in febrile infants vaccinated greater than 24 hours prior to presentation was 8.9% (95 CI = 1.5 to 16.4). The relative risk of SBI with RI was 0.41 (95% CI = 0.19 to 0.90). All SBIs in the RI infants were urinary tract infections (UTI). Conclusions: Among febrile infants, the prevalence of SBI is less in the initial 24 hours following immunizations. However, there is still a substantial risk of UTI. Therefore, urine testing should be considered in febrile infants who present within 24 hours of immunization. Infants who present greater than 24 hours after immunizations with fever should be managed similarly to infants without RIs.     

Cytomegalovirus gB genotype and clinical features in Chinese infants with congenital infections

OBJECTIVE: To investigate cytomegalovirus (CMV) glycoprotein B (gB) genotypes and clinical features in Chinese infants with congenital infections. METHODS: Urine samples were obtained from 79 infants with human CMV infection confirmed by quantitative fluorescence polymerase chain reaction (PCR). A fragment of the gB gene was amplified by nested PCR. CMV gB genotyping was carried out by restriction fragment length polymorphism, and 24 samples of the amplified DNA fragments were verified by DNA sequencing. RESULTS: The levels of CMV DNA in symptomatic and asymptomatic infants were 2.95 x 10(5) and 4.5 x 10(3) copies/ml, respectively, with a significant difference (p < 0.001). In all these cases, the most prevalent genotype was gB1 (50.63%), followed by gB3 (21.52%), gB2 (17.72%), and coinfection (10.13%); gB4 was not found. Moreover, gB1 was more prevalent in infants with liver damage (22/32) than in other symptomatic infants without liver damage (8/22, p = 0.019) or asymptomatic infants (10/25, p = 0.030). The homology of CMV gB in the 24 strains amplified as compared with the sequences of prototype strains in GenBank ranged from 97.06 to 99.64%. CONCLUSIONS: The restriction fragment length polymorphism analysis of CMV gB genotypes was definite and reliable. The gB1 genotype is the most prevalent in Chinese infants with congenital CMV disease, especially in those with liver damage, followed by genotypes gB3, gB2, and gB4.     

Pediatric out-of-hospital cardiac arrest in Korea: A nationwide population-based study

Study objectives

Our objective was to describe the incidence and demographics of pediatric out-of-hospital cardiac arrest (OHCA) in Korea.

Methods

We identified non-traumatic OHCA patients aged less than 20 years from a Korean nationwide OHCA registry (2006-2007). Data from emergency medical service (EMS) run-sheets and hospital records were reviewed. We excluded cases with unknown hospital outcomes. Patient characteristics, treatment by EMS, and outcomes were compared by age groups: infant (<1 year), children (1-11 years), and adolescents (12-19 years).

Results

A total of 971 patients including infants (n = 299, 30.8%), children (n = 305, 31.4%), and adolescents (n = 367, 37.8%) met inclusion criteria. The incidence of pediatric OHCA was 4.2 per 100,000 person-years (67.1 in infants, 2.5 in children, and 3.5 in adolescents). The rate of cardiopulmonary resuscitation administered was 82.1% (infants 80.6%, children 82.0%, and adolescent 83.4%). The rate of applying automated external defibrillators and advanced airway management (endotracheal intubation or laryngeal mask airway), was only 4.1% and 2.5%, respectively. 7.4% showed ventricular fibrillation (VF) or pulseless ventricular tachycardia (VT) in the initial ECG. Survival to hospital discharge for all pediatric OHCA was 4.9% (2.9% for infants, 4.7% for children, and 7.2% of adolescents). For EMS-treated pediatric OHCA or patients with VF or pulseless VT, the rate was 5.0% and 31.6%, respectively.

Conclusion

Incidence and hospital outcomes in pediatric OHCA in Korea were comparable to other population-based nationwide reports.     

Procedural pain in newborns at risk for neurologic impairment

In the past decade, our knowledge of pain in newborn infants has advanced considerably. However, infants at significant risk for neurologic impairment (NI) have been systematically excluded from almost all research on pain in neonates. The objectives of this study were to compare: (a). the nature, frequency and prevalence of painful procedures, (b). analgesics and sedatives administered, and (c). the relationship between painful procedures and analgesia for neonates at risk for NI. One hundred and ninety-four infants at high (cohort A, n=67), moderate (cohort B, n=59) and low (cohort C, n=68) risk for NI from two tertiary level Neonatal Intensive Care Unit's in Canada were included in a retrospective cohort study on the first 7 days of life. Data were collected from medical records and analyzed using chi-square, ANOVA and regression approaches. All cohorts had a mean of >10 painful procedures per day during the first 2 days of life. There was an interaction effect between cohort group and day of life (F(5,188)=2.13, P<0.06) with cohort A having significantly more painful procedures on day 1 (F(2,191)=4.79, P<0.009). There was no statistical difference in the number of infants who received continuous infusion (F(2,20)=1.9, P=0.13) or bolus (F(2,20)=1.3, P=0.25) opioids or sedatives (F(2,20)=0.45, P=0.84) by cohort over the 7 day period. There was a statistical difference in bolus opioid administration for days 1 (P<0.05) and 2 (P<0.001) with less than 10% of infants in cohort A receiving bolus opioids compared with approximately 22-33% of infants in cohorts B and C. There was a statistically significant correlation between painful procedures and analgesic use (r=0.29, P<0.001), although significant associations existed for cohorts B and C only. The number of painful procedures and study site primarily accounted for the variance (61% in cohort B and 35% in cohort C) in analgesic use, while in cohort A, only study site contributed to the variance (16%). Neonates at the highest risk for NI had the greatest number of painful procedures and the least amount of opioids administered during the first day of life. There was no relationship between painful procedures and analgesic use in this group. As these infants are vulnerable to pain and its consequences, the rational underlying health professional strategies regarding painful procedures and analgesic use for procedural pain in this population urgently awaits exploration.     

The Clinical Utility of the Rectal—Skin Temperature Difference in the Assessment of Young Infants

OBJECTIVE: Previous studies have suggested that the degree of difference between rectal temperature and peripheral skin temperature [rectal-skin temperature difference (RSTD)] is predictive of serious illness in young infants. The authors sought to determine the clinical utility of the RSTD in the outpatient evaluation of infants up to 2 months of age for serious infectious illness (SII). METHODS: Simultaneous rectal and skin (anterior mid-lower leg) temperatures were recorded for all infants < or = 2 months of age seen in the ED over a one-year period. The physician's clinical assessment, rectal temperature, skin temperature, laboratory results, and final diagnoses were also recorded. The RSTD (rectal temperature - skin temperature) was calculated for each infant. Final diagnoses were recorded and classified as SII or nonserious illness (NSI). Mean RSTD for each group was calculated and data were analyzed by the Wilcoxon rank sum test and multivariate regression model. RESULTS: A total of 601 infants [mean age of 28 days (range 2-65 days)] were enrolled. Nine percent (57 of 601) of infants had SII. Forty percent (23 of 57) of infants with SII were febrile, and 60% (34 of 57) were afebrile. The mean RSTD of febrile infants with SII was 5.8 +/- 1.7 degrees C (range 3.2-9.7 degrees C) and 5.3 +/- 1.4 degrees C (range 3.0-7.6 degrees C) for febrile infants with NSI. The mean RSTD of afebrile infants with SII was 4.8 +/- 1.8 degrees C (range 2-12.5 degrees C) and 4.4 +/- 1.5 degrees C (range 0.04-10.9 degrees C) for afebrile infants with NSI. The RSTD was not associated with SII in either febrile or afebrile infants (p > 0.05, Wilcoxon rank sum test). A multivariate logistic regression model of age, rectal temperature, and RSTD suggested an independent association of rectal temperature with SII (p < 0.0001), but none between age or RSTD and SII (p > 0.05). CONCLUSION: Once the rectal temperature is known, the RSTD is not a clinically useful test in the evaluation of young infants for serious infectious illness.     

Plasma sRAGE enables prediction of acute lung injury after cardiac surgery in children

ABSTRACT: INTRODUCTION: Acute lung injury (ALI) after cardiac surgery is associated with a high postoperative morbidity and mortality, but few predictors are known for the occurrence of the complication. This study evaluated whether elevated plasma levels of soluble receptor for advanced glycation end products (sRAGE) and S100A12 reflected impaired lung function in infants and young children after cardiac surgery necessitating cardiopulmonary bypass (CPB). METHODS: Consecutive children younger than 3 years after cardiac surgery were prospectively enrolled and assigned to ALI and non-ALI groups, according to the American-European Consensus Criteria. Plasma concentrations of sRAGE and S100A12 were measured at baseline, before, and immediately after CPB, as well as 1 hour, 12 hours, and 24 hours after operation. RESULTS: Fifty-eight patients were enrolled and 16 (27.6%) developed postoperative ALI. Plasma sRAGE and S100A12 levels increased immediately after CPB and remained significantly higher in the ALI group even 24 hour after operation (P < 0.01). In addition, a one-way MANOVA revealed that the overall sRAGE and S100A12 levels were higher in the ALI group than in the non-ALI group immediately after CPB (P < 0.001). The multivariate logistic regression analysis showed that the plasma sRAGE level immediately after CPB was an independent predictor for postoperative ALI (OR, 1.088; 95% CI, 1.011 to 1.171; P = 0.025). Increased sRAGE and S100A12 levels immediately after CPB were significantly correlated with a lower PaO2/FiO2 ratio (P < 0.01) and higher radiographic lung-injury score (P < 0.01), as well as longer mechanical ventilation time (sRAGEN: r = 0.405; P = 0.002; S100A12N: r = 0.322; P = 0.014), longer surgical intensive care unit stay (sRAGEN: r = 0.421; P = 0.001; S100A12N: r = 0.365; P = 0.005) and hospital stay (sRAGEN: r = 0.329; P = 0.012; S100A12N: r = 0.471; P = 0.001). CONCLUSIONS: Elevated sRAGE and S100A12 levels correlate with impaired lung function, and sRAGE is a useful early biomarker of ALI in infants and young children undergoing cardiac surgery.     

Autonomic nervous system function in infants with transposition of the great arteries

The ability to maintain and respond to challenges to homeostasis is primarily a function of the autonomic nervous system (ANS). In infants with complex congenital heart defects this ability may be impaired. This study described change in ANS function before and after surgical correction in infants with transposition of the great arteries (TGA) and in healthy infants. A total of 15 newborn infants with TGA were matched with 16 healthy infants on age, gender, and feeding type. The ANS function was measured using heart rate variability (HRV). Data were collected preoperatively in the 1st week of life and postoperatively before, during, and after feeding at 2 weeks and 2 months of age. Infants with TGA demonstrated significantly lower high-frequency and low-frequency HRV preoperatively (p < .001) when compared with healthy infants. At 2 weeks, infants with TGA were less likely than healthy infants to demonstrate adaptive changes in high-frequency HRV during feeding (Wald Z = 2.002, p = .045), and at 2 months, 40% of TGA infants exhibited delayed postfeeding recovery. Further research is needed to more thoroughly describe mechanisms of a physiologically adaptive response to feeding and to develop nursing interventions supportive of these high-risk infants.     

Spectral analysis of systemic and cerebral cardiovascular variabilities in preterm infants: relationship with clinical risk index for babies (CRIB)

Frequency spectrum analysis of circulatory signals has been proposed as a potential method for clinical risk assessment of preterm infants by previous studies. In this study, we examined the relationships between various spectral measures derived from systemic and cerebral cardiovascular variabilities and the clinical risk index for babies (CRIB II). Physiological data collected from 17 early low birth weight infants within 1-3 h after birth were analysed. Spectral and cross-spectral analyses were performed on heart rate variability, blood pressure variability and cerebral near-infrared spectroscopy measures such as oxygenated and deoxygenated haemoglobins (HbO(2) and HHb) and tissue oxygenation index (TOI). In addition, indices related to cardiac baroreflex sensitivity and cerebral autoregulation were derived from the very low, low- and mid-frequency ranges (VLF, LF and MF). Moderate correlations with CRIB II were identified from mean arterial pressure (MAP) normalized MF power (r = 0.61, P = 0.009), LF MAP-HHb coherence (r = 0.64, P = 0.006), TOI VLF percentage power (r = 0.55, P = 0.023) and LF baroreflex gain (r = -0.61, P = 0.01 after logarithmic transformation), with the latter two parameters also highly correlated with gestational age (r = -0.75, P = 0.0005 and r = 0.70, P = 0.002, respectively). The relationships between CRIB II and various spectral measures of arterial baroreflex and cerebral autoregulation functions have provided further justification for these measures as possible markers of clinical risks and predictors of adverse outcome in preterm infants.